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B.   DALSTON, 
MEOICAl  BOOKS. 
612  Jefferson  Ave., 

BROOKLTN,  N. 


Columbia  ^niber^itp 
mtf)ECitpo(i^ebj|9orfe 

College  of  ^fjpgiciansi  anb  ^urgeong 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonappendOOdeav 


APPEI^DICITIS 


BY    THE    SAIVJE    AUTHOR 


TREATISE 


SURGICAL  ANATOMY 


Large  Octavo.  Containing  over  800  pages 
and  upward  of  200  Illustrations  drawn  ex- 
pressly for  this  work  from  actual  dissections. 


NOW   ON    PR  ESS 


Dr.  G.  SANDERS 


TREATISE 


ON 


APPENDICITIS, 


JOHIN^    B.   DEATER,   M.D 

SURGEON   TO   THE   GERJIA^T   HOSPITAL,    PHILADELPHIA 


CONTAINING 


32  fuiUpagc  plates  au&  ©tber  IFUustrations 


PHILADELPHIA 
p.   BLAKISTON,   SON    &    CO 

1012    WALNUT    STREET 

1896 


Copyright,  1896,  by  P.  Blakiston,  Son  &  Co. 


Press  of  Wm.  F.  Fell  &  Co., 

1220-24  SANSOM  ST., 

PHILADELPHIA. 


TO   THE   MEMORY   OF   MY   FATHER 

J.  M.   DEAVER,  M.D. 

WHOSE    CHAEACTEE    AND    STEELING    QUALITIES   AS   A    PHYSICIAN 

HAVE  BEEN  THE  GUIDING   INFLUENCES  OF  MY 

PEOFESSIONAL  LIFE 

S^^ts  ^ooh  is  ^ffcctionatelg  Jlcbitateir 


PREFACE. 


The  following  work  on  appendicitis  has  been  prompted  by 
the  belief  that  the  importance  of  this  affection  entitles  it  to  a 
more  thorough  and  exhaustive  study  than  has  usually  here- 
tofore been  accorded  it.  Appendicitis  in  a  general  way  has 
been  so  widely  and  thoroughly  discussed  that  in  its  usual 
forms  its  diagnosis  is  comparatively  devoid  of  difficulty.  No 
inflammatory  affection  of  the  abdominal  cavity,  however,  is 
capable  of  such  varied  symptoms  and  of  so  many  serious  com- 
plications, all  of  which  demand  the  most  thorough  knowledge 
for  their  proper  treatment. 

It  has  been  my  desire  to  present  in  this  volume  such  a  sys- 
tematic study  of  the  disease  that  not  only  the  usual  symptoms 
may  be  traced  from  their  inception  to  their  termination,  but 
also  that  the  various  anomalous  conditions  so  frequently  met 
with  may  be  recognized  with  equal  facility. 

I  have,  therefore,  endeavored  to  emphasize  the  aetiology, 
symptomatology,  and  special  technique  in  the  operative  treat- 
ment. The  observations  herein  contained  are  the  result  of  an 
experience  in  the  treatment  of  over  five  hundred  cases. 

I  wish  to  express  my  thanks  to  m}^  assistants.  Dr.  L.  Brink- 
mann,  Dr.  George  Ross,  Dr.  A.  D.  Whiting,  my  brother.  Dr. 
H.  C.  Deaver,  and  to  Dr.  Wilmer  R.  Batt,  for  valuable  aid  in 
the  preparation  of  the  book,  and  to  Dr.  W.  S.  Dougherty,  my 
surgical  interne  at  the  German  Hospital,  for  preparing  many 
case  reports  and  for  correcting  all  the  proof-sheets. 

vii 


Vlll  PREFACE. 


A  number  of  the  pathological  drawings  were  made  b}^  Dr. 
C.  Frese,  and  to  him  and  the  excellent  artistic  work  of  Mr.  F- 
von  Iterson  is  due  the  accuracy  of  that  series.  I  wish  also  to 
express  my  grateful  acknowledgment  of  numberless  services 
performed  by  Dr.  Frese  as  Medical  Superintendent  of  the 
German  Hospital,  where  I  have  done  the  larger  part  of  the 
surgical  work  here  represented. 

John  B.  Deaver,  M.  D. 

1634  Walnut  Street. 


CONTENTS. 


PAGE 

History, 17 

Anatomy, 23 

Etiology, 31 

Pathology, 45 

Sy'Mptoms, 73 

Diagnosis, 84 

diffeeextial  diagnosis, 94 

Prognosis, 113 

Treatment, 116 

Complications  and  SEQUELiE, 148 

Aftee-Teeatment, 161 


IX 


DESCRIPTION  OF  PLATES. 


PAGE 

Plate  I, 24 

The  four  types  of  caecum,  and  relation  of  appendix  to  each. 


Plate  II, 26 

The  ileo-colic  fossa. 

Plate  III, 28 

The  ileo-csecal  fossa,  and  relative  positions  of  appendix  and  meso- 
appendix. 

Plate  IV, 30 

The  sub-ca;cal  fossa. 

Plate  V, 30 

An  unusual  position  of  the  appendix,  showing  it  adherent  to  the 
posterior  side  of  the  cpecum  and  covered  by  its  serous  coat. 

Plate  VI, 36 

Appendix  containing  pin  which  entered  the  canal  point  first,  perfo- 
rating the  wall,  the  head  afterward  lodging  in  the  distal  end 
of  the  canal. 

Plate  VII, 42 

Appendix  ulcerated  oflf  ceecum,  showing  gangrenous  condition 
caused  by  pressure  of  large  faecal  concretion. 

xi 


Xll  DESCRIPTION    OF   PLATES. 

PAGE 

Plate  VIII, 44 

Appendix,  showmg  gangrenous  condition  and  perforations  on  distal 
side  of  fnecal  concretion. 


Plate  IX,     48 

Fig.  1.  The  condition  of  the  blood-vessels  in  acutely  inflamed 
appendix. 

Fig.  2.  Appendix  laid  open,  showing  gangrenous  tissue,  mucus, 
and  pus,  the  result  of  degeneration  of  the  lining  membrane. 

Plate  X, 52 

Fig.  1.  Appendix  inflamed,  showing  adhesions  and  change  in  posi- 
tion caused  by  occlusion  of  the  lumen. 

Fig.  2.  Appendix  laid  open,  showing  pus  cavities  and  complete 
occlusion  of  the  lumen. 

Plate  XI, 54 

Appendix  gangrenous  and  perforated,  showing  the  result  of  occlu- 
sion of  the  lumen,  beginning  at  a  point  other  than  the  tip. 

Plate  XII, 58 

Fig.  1.  Appendix  congested,  with  point  of  beginning  iilceration 
near  the  tip. 

Fig.  2.  Appendix  laid  open,  showing  ulcerated  area  and  oblitera- 
tion of  lumen. 

Plate  XIII 62 

Appendix,  showing  formation  of  adhesions  as  a  barrier  against 
general  infection  of  the  peritoneal  cavity. 

Plate  XIV, 66 

Fig.  1.  Appendix  adherent  to  csecum. 

Fig.  2.  Perforation  in  ca;cum,  evident  after  detachment  of  appendix. 

Fig.  3.   Perforation  in  appendix  corresponding  to  that  in  c£ECum. 


DESCRIPTION    OP    PLATES.  Xlll 

PAGE 

Plate  XV, 68 

Appendix  which  was  imbedded  iu  abscess  Avail,  showing  eiilarge- 
raeut,  acute  inflammation,  and  perforation. 


Plate  XVI, 106 

Tubercular  appendix. 

Plate  XVII, 128 

Caecum  laid  open,  showing  necrotic  area  and  two  perforations. 

Plate  XVIII, 130 

Location  of  the  simple  incision. 

Plate  XIX, 130 

Fig.  1.  Incision  through  skin  and  superficial  fascia  to  aponeurosis 
of  external  oblique. 

Fig.  2.  Division  of  aponeurosis  of  external  oblique,  expoi^ing  apo- 
neurosis of  internal  oblique  and  sheath  of  rectus. 

Plate  XX, 132 

Fig.  1.  Division  of  sheath  of  rectus,  exposing  the  muscle. 
Fig.  2.  Rectus  drawn  aside,  showing  transversalis  fascia  and  loca- 
tion of  epigastric  veins. 

Plate  XXI, 134 

Fig.  1.  Division  of  transversalis  fascia,  showing  pre-peritoneal  fat 

and  epigastric  veins. 
Fig.  2.  Exposure  of  peritoneum. 

Plate  XXII, 136 

Fig.  1.  Great  omentum,  seen  through  incision  in  peritoneum. 
Fig.  2.  Exposure  of  caecum  and  appendix. 


XIV  DESCRIPTION    OF    PLATES. 

PAGE 

Plate  XXIII, 136 

Fig.  1.  Gauze  distributed  around  bowel,  serous  coat  turned  back, 

aud  appendix  tied  off. 
Fig.  2.  Serous  coat  of  aijpendix  sutured  OA^er  stump. 

Plate  XXIV, 138 

Fig.  1.  Stump  of  appendix  invaginated. 

Fig.  2.  Caecum  replaced  and  gauze  laid  beneath  peritoneal  covering. 

Plate  XXV, 140 

Location  of  the  McBurney  incision. 

Plate  XXVI, 140 

Fig.  1.  Incision  through  skin  and  superficial  fascia  to  aponeurosis 

of  external  oblique. 
Fig.  2.  Delicate  fascia  covering  internal  oblique. 

Plate  XXVII, 142 

Fig.  1.  Internal  oblique  muscle. 

Fig.   2.    Fibres   of  internal  oblique  and   transversalis   separated, 
showing  transversalis  fascia. 

Plate  XXVIII, 142 

Fig.  1.  Division  of  transversalis  fascia,  and  pre-peritoueal  fat,  and 

exposure  of  peritoneum. 
Fig.  2.  Great  Omentum. 

Plate  XXIX, 144 

Fig.  1.  Exposure  of  csecum,  appendix,  and  meso-appendix. 
Fig.  2.  Gauze  distributed  around  bowel,  serous  coat  turned  back, 
and  appendix  tied  off. 

Plate  XXX, 146 

Fig.  1.  Serous  coat  sutured  over  stump. 
Fig.  2.  Stump  invaginated. 


DESCRIPTION    OF    PLATES.  XV 

PAGK 

Plate  XXXI, 146 

Fig.  1.  Caecum  replaced,  preparatory  to  closure  of  wound. 
Fig.  2.  Position  of  layers  when  wound  is  ready  to  be  closed. 

Plate  XXXII, 158 

Fig.  1.  Appendix,  of  which  part  sloughed  away  after  evacuation  of 

abscess. 
Fig.  2.  Fistulous  tracts  in  communicatiou  with  sloughing  appendix. 


APPENDICITIS. 


HISTOKT. 

A  review  of  the  history  of  the  inflammatory  affection  in  the 
right  iliac  fossa,  now  recognized  as  a  disease  of  the  vermiform 
appendix,  discloses  many  facts  that  account  for  the  great 
diversit}'-  of  opinions  of  earlier  observers.  During  the  first 
half  of  the  present  century,  although  cases  had  been  reported 
in  which  perforation  of  the  appendix  had  been  found,  almost 
all  inflammatory  conditions  localized  in  the  right  iliac  fossa 
were  ascribed  to  diseases  of  the  caecum.  It  is  probable  that 
lack  of  knowledge  of  the  distribution  of  the  peritoneum  served 
in  part  to  account  for  this  condition  of  affairs,  as  the  older 
writers  held  that  this  serous  membrane  was  found  only  as  a 
covering  for  the  solid  viscera  contained  in  the  abdominal 
cavity.  In  the  year  1803  Laennec  first  gave  a  complete 
description  of  the  peritoneum.  His  investigations  stimulated 
further  observations  of  this  membrane,  but  as  yet  there  was  no 
association  of  the  fact  of  inflammation  of  the  general  peri- 
toneum with  disease  in  the  right  iliac  fossa, — that  is,  the  latter 
condition  was  not  considered  as  causal  of  the  former  inflam- 
mation. The  symptoms  of  the  affection  found  in  the  right 
iliac  fossa  were  described  with  minuteness  and  accuracy,  but 
the  conditions  were  not  held  responsible  for  the  general 
peritonitis.  Even  in  post-mortem  records  of  cases  of  peritoni- 
tis, no  mention  is  made  of  the  affection  of  the  appendix  as  a 
direct  cause  of  the  fatal  peritonitis. 
2  17 


18  APPENDICITIS. 

The  first  authentic  record  of  the  distinct  localization  of  a 
lesion  in  the  vermiform  appendix  was  that  of  Mestivier,  who 
in  1759  recorded  a  case  of  perforation  of  this  organ.  Nothing 
of  importance  was  gained  by  the  knowledge  of  this  case,  except 
that  such  a  lesion  could  exist. 

In  1827  Husson  and  Dance  described  the  diseases  of  the 
csecum  more  in  detail,  and  in  1824,  Louyer  Villermey  reported 
a  case  of  fatal  peritonitis,  giving  perforation  of  the  appendix 
as  the  direct  cause.  This  was  the  first  recorded  case  in  which 
the  true  seat  of  the  origin  of  the  disease  was  recognized. 
Melier,  in  1827,  reported  four  cases,  three  of  which  he  described 
as  cases  of  perforative  appendicitis  with  fulminating  peritonitis ; 
the  fourth  was  a  case  of  relapsing  appendicitis.  Both  Louyer 
Villermey  and  Melier,  however,  believed  that  diseases  of  the 
appendix  and  of  the  CEecum  were  separate  and  distinct.  Melier 
described  the  appendiceal  disease  very  fully,  and  made  special 
mention  of  two  distinct  symptoms  in  the  perforative  cases,  viz., 
more  or  less  severe  abdominal  colic,  and  fixed  pain  in  the 
right  iliac  fossa.  He  considered  the  causes,  the  character,  and 
the  consequences  of  appendicitis,  and  even  anticipated  the 
possible  advantage  of  operation.     He  says : — 

"  If  it  were  possible  to  establish  with  certainty  the  diagnosis  of 
this  affection,  we  could  see  the  possibility  of  curing  the  patient  by 
an  operation.    We  shall,  perhaps,  some  day  arrive  at  this  result." 

In  1831,  Ferrall  published  a  monograph  on  "  Phlegmonous 
Tumors  in  the  Right  Iliac  Fossa,"  in  which  he  held  that  in 
these  conditions  the  csecum  is  the  organ  primarily  involved, 
and  that  the  appendix  and  the  peritoneum  do  not  enter  as 
factors  in  the  production  of  the  phlegmon  to  as  great  an  extent 
as  does  the  retro-csecal  connective  tissue.  He  recognized  three 
varieties  of  tumors,  (a)  a  faecal  impaction  or  distention  of  the 
caecum  without  inflammation;  (6)  a  malignant  tumor  of  the 
caecum ;  (c)  a  true  inflammatory  or  phlegmonous  tumor,  the 


HISTORY.  19 

result  of  irritation  of  the  mucous  membrane  of  the  caecum,  or 
the  result  of  ulceration  and  perforation  of  its  wall.  He  also 
mentions  a  thickened  condition  of  the  peritoneum  covering 
the  ceecum  as  having  been  found  in  the  phlegmonous  tumor. 

In  1833,  Dupuytren  recorded  observations  showing  the  con- 
nection between  abscess  of  the  right  iliac  fossa  and  disease  of 
the  csecum,  and  it  is  largely  due  to  this  great  authority  that  the 
caecum  as  the  primary  seat  of  the  cause  of  peri-typhlitis  was  so 
widely  accepted.  In  Dupuytren's  post-mortem  reports,  no 
mention  is  made  of  the  appendix  as  the  original  seat  of  the 
disease,  and  nowhere  in  his  writings  does  he  associate  the 
appendix  with  the  cause  of  the  inflammation  of  the  csecum. 

In  1834,  Copland,  in  his  "  Dictionary  of  Practical  Medicine," 
made  an  advance  in  the  pathology  of  the  troubles  in  the  right 
iliac  fossa.  He  entered  upon  the  study  of  the  diseases  of  the 
CEecum  in  great  detail,  and  claimed  that  inflammation  of  the 
appendix  can  be  the  primary  cause  of  serious  affection  in  the 
region  of  the  csecum.  He  also  speaks  of  the  mortification  of 
the  appendix,  followed  by  a  fatal  peritonitis,  as  the  result  of  a 
foreign  body  found  within  that  organ. 

In  1837,  Burne  strove  to  separate  clinically  the  appendix  from 
the  csecum,  although  he  agreed  with  the  writers  of  that  time, 
that  in  the  troubles  of  the  right  iliac  fossa  the  csecum  is 
primarily  the  seat  of  the  disease.  He  mentions  ulceration  of 
the  appendix  due  to  a  process  set  up  by  foreign  bodies,  such  as 
cherry-stones,  raisin-seeds,  and  fsecal  concretions,  and  adds : — 

"So  long  as  ulceration  is  limited  to  the  mucous  membrane, 
it  is  of  little  consequence,  but  immediately  the  peritoneum  is 
perforated  inflammation  ensues ;  then  there  is  general  peri- 
tonitis, or  local  peritonitis  with  abscess." 

In  1839  he  wrote  a  second  paper,  in  which  he  endeavors  to 
show  that  the  csecum  is  of  little  importance  in  affections  of  the 
right  iliac  fossa. 


20  APPENDICITIS. 

In  1838,  Albers  noted  the  possibility  of  disease  of  the  right 
iliac  fossa  occurring  as  the  result  of  inflammation  of  the 
vermiform  appendix,  but  he  thought  that  it  is  more  frequently 
caused  by  disease  of  the  caecum.  Under  the  name  typhlitis, 
he  described  the  following  varieties  of  inflammation  localized 
about  the  csecum  : — 

1.  Stercoral  typhlitis — stagnation  of  faecal  matter  in  the 
csecum,  with  subsequent  irritation. 

2.  Simple  typhlitis — catarrhal  inflammation  due  to  a  multi- 
tude of  causes. 

3.  Peri-typhlitis — extension  of  the  inflammation  of  the  mu- 
cous membrane  to  the  external  coat  of  the  csecum  and  to 
the  surrounding  parts. 

4.  Chronic  typhlitis — in  which  there  is  a  prolonged  and  slow 
course.  When  pus  is  present  and  associated  with  a  perforated 
appendix,  he  believed  that  the  perforation  occurs  as  a  con- 
sequence of  the  pus  formation. 

In  writing  of  the  csecum,  in  1839,  Grisolle  made  mention 
of  fatal  cases  of  appendiceal  gangrene.  In  1840,  Villerfne}^ 
reported  cases  of  inflammation  of  the  appendix  that  termi- 
nated rapidly  in  gangrene  and  death.  In  1843,  Voltz  published 
a  paper  on  "  Ulceration  and  Perforation  of  the  Appendix, 
Occasioned  by  Foreign  Bodies."  His  general  conclusions 
were  that  the  appendix  was  responsible  for  more  of  the 
affections  of  the  right  iliac  fossa  than  was  the  csecum.  Roki- 
tansky  was  the  first  to  describe  catarrhal  inflammation  of 
the  appendix  as  due  to  fsecal  concretions  or  foreign  bodies, 
and  believed  that  this  might  result  either  in  ulceration  or 
in  a  chronic  morbid  condition.  He  also  suggested  that  a 
general  peritonitis,  as  a  consequence  of  perforation  of  the 
appendix,  is  not  always  necessary,  because  of  adhesions  to  the 
surrounding  structures  prior  to  the  perforation.  He  thought 
these  adhesions  were  due  to  a  previous  irritation. 


HISTORY.  21 

Although  the  view  that  the  grave  and  fatal  forms  of  typhli- 
tis are  due  to  perforation  of  the  appendix  gained  ground,  yet 
all  of  the  benign  and  curable  forms  were  considered  as  the 
result  of  inflammation  of  the  caecum  and  of  the  surrounding 
cellular  tissue.  This  theory  has  still  a  few  advocates,  but, 
fortunately,  they  grow  less  numerous  each  year. 

This  much-vexed  question  has  been  restored  to  the  status  to 
which  Melier  advanced  it  by  the  surgeons  and  physicians  of 
the  United  States,  who,  by  early  operation,  have  demonstrated 
that  inflammation  of  the  right  iliac  fossa  is  invariably  due, 
primarily,  to  disease  of  the  vermiform  appendix.  Hancock, 
in  ]  848,  operated  on  one  case.  He  advocated  early  operation 
in  disease  of  the  appendix,  but  his  ideas  met  with  no  encour- 
agement. In  1867,  Willard  Parker,  of  New  York,  first  proved 
that  early  operation  would  save  75  per  cent,  of  all  cases.  In 
1883,  Dr.  F.  F.  Noyes  reported  100  cases  operated  upon,  90  per 
cent,  of  the  operations  having  been  performed  in  America. 

"  The  epoch-making  memoir  on  this  subject "  (I  quote  from 
Talamon)  "is  the  paper  of  Reginald  Fitz,  of  Boston,  published 
in  the  American  Journal  of  the  Medical  Sciences  for  October, 
1886,  '  On  Perforative  Inflammation  of  the  Vermiform  Appen- 
dix.' In  this  work  Fitz  collected  reports  of  209  cases  of 
t3'^phlitis  and  peri-typhlitis,  and  257  cases  of  perforative  appen- 
dicitis. He  showed  that  the  sj^mptoms  are  the  same  in  the 
latter  as  in  the  former  class  of  cases.  He  studied  with  care  the 
consequence  of  perforation.  He  established  the  fact  that  the 
peritonitis  is  not  always  generalized,  that  it  may  be  circum- 
scribed under  the  form  of  an  encysted  purulent  collection.  He 
gave  the  characters  of  the  tumors  formed  by  this  localized 
peritonitis,  the  different  modes  of  the  evacuation  of  the  pus, 
the  complications  that  may  supervene  if  the  disease  be  left  to 
itself.  He  insisted  on  the  frequency  of  faecal  concretions  as  a 
cause  of  the  perforation  of  the  appendix.     He  concludes  in 


22  APPENDICITIS. 

favor  of  early  operation."  In  1<S88,  Fitz  published  a  second 
paper  in  which  he  advanced  the  radical  but  sound  theory  that 
the  diseases  described  as  typhlitis,  peri-typhlitis,  para-typhlitis, 
appendicular  peritonitis,  and  peri-typhlitic  abscess  are  all 
varieties  of  one  and  the  same  affection,  namely,  appendicitis. 
Since  1888  the  subject  of  appendicitis  has  occupied  a  large 
proportion  of  the  time  and  labor  of  the  medical  profession,  and 
many  able  papers  have  been  published  advancing  widely  dif- 
ferent views  and  ideas  in  regard  to  it.  The  most  debated 
points  have  been  concerning  the  diagnosis  and  the  treatment, 
and  about  these  the  discussion  has  waged,  generally  with 
physicians  and  surgeons  as  the  opposing  disputants. 

The  frequency  of  the  affection ;  the  rapidity  with  which  the 
disease  may  proceed  from  bad  to  worse ;  the  fatality  in  a  large 
percentage  of  cases ;  its  marked  tendency  to  occur  or  recur  in 
those  who  apparently  recover  from  an  attack, — these  things 
make  appendicitis  the  most  important  intra-abdominal  lesion 
of  to-day.  The  work  of  McBurney,  Richardson,  Murphy, 
Morris,  and  others  has  greatly  advanced  the  state  of  our 
knowledge  of  the  affection,  and  has  done  much  to  present  the 
subject  in  such  a  light  that  the  surgeon  has  been  enabled 
to  cope  with  the  disease  in  a  more  satisfactory  and  life-saving 
manner.  Physicians  generally,  however,  take  the  stand  that 
only  a  minority  of  cases  require  the  services  of  the  surgeon, 
and  they  claim  that  only  those  cases  that  advance  to  suppura- 
tion, gangrene,  and  perforation  should  be  seen  by  the  surgeon. 
Thus  the  controversy  still  continues,  although  prominent 
physicians  of  the  present  day  grant  that  it  is  advisable  to  have 
a  surgeon  in  consultation,  even  if  they  do  not  always  give  the 
surgeon  the  privilege  of  treating  the  disease  as,  in  my  opinion, 
it  invariably  should  be  treated, — namely,  by  early  operation. 


Al^ATOMY. 

The  appendix  vermiformis  of  man  is  the  undeveloped  true 
CEecum  of  some  of  the  lower  animals.  In  the  embryologic 
development  of  the  human  intestinal  tract,  there  is  at  first 
no  csecum  present,  the  original  tract  consisting  of  a  straight 
tube,  which  has  been  divided  into  the  foregut,  midgut,  and 
hindgut,  each  division  giving  rise  to  different  structures. 
From  the  midgut  springs  a  diverticulum  marking  the  divi- 
sion between  the  large  and  the  small  intestine.  This 
conical  projection  lengthens  to  form  the  caecum,  "  but  the 
terminal  portion  does  not  keep  pace  with  the  growth  of  the 
base,  and  consequently  becomes  much  narrower  in  calibre. 
The  basal  portion  eventually  grows  so  large  that  it  is  com- 
monly called  the  csecum,  while  the  true  csecum  is  designated 
as  the  vermiform  appendix."  During  the  early  stages  of 
intra-uterine  life,  the  csecum  with  the  vermiform  appendix 
lies  near  the  umbilicus,  its  descent  into  the  right  iliac  fossa 
occurring  about  the  sixth  month. 

In  the  adult,  the  csecum  occurs  as  one  of  four  types,  and 
in  each  the  appendix  holds  a  different  position.     (Plate  I.) 

1.  In  the  foetal  type,  the  appendix  is  the  narrow  inferior 
end  of  a  conical  csecum,  the  apex  of  the  cone  being  directly 
continued  into  the  appendix. 

2.  A  second  type  consists  of  a  csecum,  with  two  equally 
large  sacculi  at  its  inferior  termination ;  between  the  sacculi, 
which  are  separated  by  the  anterior  longitudinal  band,  the 
appendix  arises. 

3.  In  the  third  class,  the  external  sacculus  is  large,  while 
the  internal  one  is  small,  thus  bringing  the  base  of  the  appen- 

23 


24.  APPENDICITIS. 

dix  nearer  the  ileo-CEecal  valve.  In  addition,  the  anterior  wall 
of  the  caecum  grows  more  rapidly  than  the  posterior,  so  that 
the  root  of  the  appendix  is  posterior. 

4.  In  the  fourth  and  last  class,  the  internal  sacculus  has 
disappeared  entirely,  and  the  base  of  the  appendix  is  attached 
posterior  to  the  receding  angle,  between  the  ileum  and  the 
csecum. 

In  cases  of  non-descent  of  the  caecum,  the  appendix  will  hold 
a  correspondingly  abnormal  position,  and,  under  such  cir- 
cumstances, may  even  lie  to  the  left  of  the  median  line.  Len- 
nander  mentions  the  case  of  a  boy  of  sixteen  in  whom  the 
csecum  and  appendix  were  found  in  the  left  hypochondriac 
region,  lying  against  the  spleen.  In  this  case  the  appendix 
measured  nine  inches  in  length.  Although  the  average  length 
of  the  appendix  is  about  four  inches,  it  may  vary  from  half  an 
inch  to  nine  inches.  When  the  appendix  is  long,  the  csecum 
is,  as  a  rule,  somewhat  shortened.  The  diameter  of  the 
appendix  is  that  of  a  goose  quill,  or  about  the  same  as  that  of 
a  large  earthworm.     (Holden.) 

Before  entering  upon  a  consideration  of  the  structure  of  the 
appendix,  it  would  be  well  to  trace  its  peritoneal  covering, 
together  with  that  of  the  csecum.  The  csecum  is  almost  always 
entirely  covered  with  peritoneum,  although  cases  have  been 
recorded  in  which  the  peritoneum,  instead  of  entirely  investing 
the  csecum,  was  reflected  from  its  posterior  surface,  thus  form- 
ing a  "meso-csecum.  Generally,  the  peritoneum  is  not,  as  a 
mesenter}^  reflected  to  the  abdominal  walls  from  the  beginning 
of  the  large  bowel  until  the  commencement  of  the  ascending 
colon  is  reached.  It  will  thus  be  seen  that  the  csecum  is  free  in 
the  abdominal  cavity,  and  that  from  various  causes  it  is  liable 
to  change  of  position.  Its  mobility  may  depend  upon  the 
presence  or  absence  of  a  meso-csecum  or  of  an  ascending  meso- 
colon, or  upon  the  length  of  the  large  bowel  between  the  tip  of 


Plate  I 


ANATOMY.  25 

the  csecum  and  the  point  of  reflection  of  the  ascending  meso- 
colon. The  organ  may  hang  over  the  brim  of  the  pelvis,  or  it 
may  even  occupy  the  pelvis,  and  cases  have  been  recorded  in 
which  it  formed  a  part  of  the  contents  of  an  inguinal  hernia 
on  the  right  side. 

The  peritoneal  covering  of  the  appendix  is  reflected  from  the 
left  or  inferior  layer  of  the  mesentery  of  the  ileum,  and  may 
entirely  or  in  part  invest  the  appendix.  The  folds  of  the 
peritoneum  reflected  from  the  ileum  to  the  appendix  usually 
form  a  mesentery  for  the  appendix,  triangular  in  shape,  the 
base  of  the  triangle  being  formed  by  the  free  edge  of  the  folds. 
The  attachment  of  the  meso-appendix  may  extend  along  the 
entire  length  of  the  appendix  (as  I  have  usually  found  it),  or 
it  may  be  attached  onl}'^  to  the  proximal  one-third  or  two- 
thirds,  thus  leaving  the  tip  free.  At  times  the  meso-appendix 
is  absent,  the  appendix,  under  such  circumstances,  being  free 
in  the  abdominal  cavity ;  generally  the  meso-appendix  has  the 
appearance  of  being  too  short,  and  thus  the  twists  and  curves 
often  found  in  the  organ  may  be  explained. 

The  meso-appendix  consists  of  two  folds  of  peritoneum, 
between  which  run  the  appendicular  artery  and  vein,  lymph- 
atics, and  a  few  sympathetic  nerve-fibers.  Occasionally  it 
contains  a  considerable  quantity  of  fat,  which  renders  it  more 
liable  to  be  torn  in  the  removal  of  the  appendix.  The  mobility 
of  the  appendix  depends  upon  the  width  and  the  length  of  the 
attachment  of  the  meso-appendix. 

At  times  an  opening  may  be  found  in  the  meso-appendix 
through  which  a  coil  of  the  small  intestine  has  been  known  to 
form  a  hernia  and  become  strangulated. 

In  some  cases  the  iliac  vessels  have  passed  through  the 
layers  of  the  meso-appendix.  This  anatomic  condition  proba- 
bly accounts  for  the  manner  in  which  collections  of  pus  in  the 
right  iliac  fossa  may  find  their  w^ay  beneath  the  fascia  lata  into 


2G  APPENDICITIS. 

the  thigh.  In  the  female  the  meso-appendix  has  a  prolonga- 
tion running  to  the  ovary,  which  is  described  by  Clado  as  the 
appendiculo-ovarian  ligament.  It  conveys  an  additional 
supply  of  blood  to  the  appendix. 

Owing  to  the  various  angles  and  projections  formed  by  the 
csecum  and  the  ileum,  there  are  fossse  formed  by  the  reflection 
of  the  peritoneum  between  these  parts  of  the  intestinal  tract, 
and  they  clinically  may  play  an  important  role.  Lockwood 
and  Rolleston  first  called  attention  to  these  fossee  and  have  so 
carefully  described  them  that  I  cannot  do  better  than  follow 
their  description  :  They  are  three  in  number,  the  ileo-colic,  the 
ileo-csecal,  and  the  sub-C8ecal. 

The  ileo-colic  fossa  (Plate  II)  is  a  peritoneal  pouch  formed  at 
the  angle  of  junction  of  the  ileum  and  colon.  The  floor  is 
formed  by  the  mesentery  and  sometimes  by  a  portion  of  the 
ileum.  The  ileo-colic  fold  of  peritoneum  forms  its  roof.  This 
pouch  is  variable  in  size  and  depth,  and  as  it  is  too  high  up 
does  not  play  a  very  important  part  in  appendicitis.  A  branch 
of  the  ileo-colic  artery  runs  through  the  ileo-colic  fold,  crossing 
in  front  of  the  ileum. 

The  ileo-csecal  fossa  (Plate  III)  is  a  peritoneal  pouch,  situated 
behind  the  angle  of  junction  of  the  ileum  and  csecum.  To 
expose  it  both  the  ileum  and  the  csecum  must  be  elevated. 
It  is  bounded  on  the  right  by  the  mesentery  of  the  ascend- 
ing colon,  and  on  the  left  by  the  mesentery  proper.  The 
roof  is  formed  by  the  ileo-c8ecal  fold,  a  bloodless  fold  of 
peritoneum  extending  from  the  free  border  of  the  ileum 
to  the  csecum  and  finally  joining  the  surface  of  the  meso- 
appendix.  This  fossa  may  be  very  deep  and  long,  at  times 
extending  upward  behind  the  ascending  colon  as  far  as 
the  kidney  and  duodenum.  The  mesentery  of  the  appendix 
sometimes  divides  the  fossa  transversely,  thus  forming  two 
fossfe,  known  as   the  superior  and    inferior  ileo-csecal   fossse. 


UJ 

i— 
<C 
_l 
Q_ 


ANATOMY.  27 

The  ileo-c<ecal  fossa  is  important,  as  the  appendix  is  often 
found  in  it,  thus  explaining  why  this  location  is  often  the  site 
of  certain  products  of  appendicular  disease. 

The  sub-csecal  fossa  (Plate  IV),  as  its  name  implies,  is  immedi- 
ately under  the  csecum,  the  latter  portion  of  the  bowel  requir- 
ing to  be  raised  in  order  to  view  it.  It  is  less  constant  than 
the  other  fossse.  The  mouth  of  this  fossa  is  found  at  the  junc- 
tion of  the  caecum  with  the  colon,  the  fossa  separating  the  la3'ers 
of  the  meso-colon.  On  account  of  its  high  position,  it  does  not 
clinically  play  a  prominent  part.  If,  however,  a  meso-csecum 
were  always  present,  this  fossa  would  be  a  very  important  one, 
as  the  mouth  of  the  fossa  would  then  be  flush  with  the  tip  of 
the  csecum,  at  the  base  of  the  appendix.  Lockwood  and 
Rolleston  have  described  this  condition  as  occurring,  but  I 
have  never  yet  seen  a  case  with  a  meso-ceecum.  The  appendix 
may  occupy  either  of  these  fossse,  but  more  often  it  is  found  in 
the  ileo-C8ecal  or  the  sub-csecal.  On  account  of  the  various 
complications  that  may  arise  if  the  appendix  occupy  either  of 
these  fossse,  the  operator  may  be  led  to  form  an  incorrect  con- 
ception of  the  true  state  of  affairs.  Thus  at  times  the 
appendix  might  constitute  a  retroperitoneal  hernia ;  or  if  the 
appendix  should  occupy  one  of  these  fossse  and  the  mouth  of 
the  fossa  should  close  over  the  organ,  the  organ  might  be 
thought  absent.  Suppuration  of  the  appendix  so  walled  in 
would  be  entirely  circumscribed. 

In  the  majority  of  cases,  the  appendix  will  hold  one  of  eight 
positions.  Dr.  Bristow  suggests  a  very  simple  method  of  clas- 
sifying these  positions  and  directions,  which  consists  in  locat- 
ing a  central  point  in  the  right  iliac  fossa  which,  in  its  most 
common  position,  will  represent  the  attachment  of  the  appen- 
dix to  the  csecum,  and  from  this  central  point  lines  are  drawn 
that  radiate-  in  eight  different  directions.  To  indicate  the 
course  of  the  different  lines,  Fowler  has  modified  this  method 


28  APPENDICITIS. 

by  substituting  the  initial  letters  of  the  points  of  the  compass 
for  the  numbers  used  by  Bristow.  The  central  point  is  located 
by  drawing  a  line  from  the  anterior  superior  spine  of  the 
ilium  to  the  umbilicus ;  a  point  on  this  line,  from  two  to  two- 
and-a-half  inches  from  the  anterior  superior  spine,  correspond- 
ing to  the  central  point  from  which  the  lines  are  drawn. 

Although,  normally,  the  appendix  may  occupy  any  of  the 
eight  j)ositions,  it  is  most  commonly  found  in  one  of  the 
following  five :  1.  It  may  lie  under  the  inferior  layer  of  the 
mesentery,  being  directed  toward  the  spleen,  in  the  N.  E.  posi- 
tion. 2.  It  may  lie  on  the  ilio-pectineal  line  or  project  into 
the  pelvis,  its  course  being  S.  or  S.  E.  3.  If  there  is  a  long 
meso-appendix,  it  may  lie  to  the  right  of  the  caecum  and  as- 
cending colon,  running  upward,  in  a  northerly  direction, 
parallel  with  the  colon  and  over  the  kidney  toward  the  right 
lobe  of  the  liver.  4.  It  may  lie  in  front  of  the  colon  and 
caecum,  its  course  generally  being  N.  or  N.  E.  5.  It  may  lie 
under  the  caecum,  holding  generally  a  northerly  direction.  If 
the  appendix  has  a  long  and  wide  mesentery,  it  may  hold  any 
of  the  other  three  positions,  freedom  of  motion  generally  being 
required  in  order  to  assume  these  positions. 

Abnormally,  the  appendix  may  hold  a  position  in  either  of 
the  ileo-caecal  fossae ;  it  may  lie  behind  the  peritoneum  and  be- 
hind the  caecum  and  adherent  to  its  posterior  muscular  wall 
(Plate  V),  being  covered  in  this  position  by  the  peritoneal 
covering  of  the  caecum  ;  it  may  be  adherent  to  the  peritoneum 
along  the  right  border  of  the  caecum  and  ascending  colon ;  it 
may  be  adherent  to  the  peritoneum  at  any  point  in  the  neigh- 
borhood of  the  caecum  ;  or  it  may  lie  in  the  inguinal  canal. 

The  structure  of  the  appendix  is  very  similar  to  that  of  the 
large  intestine,  but  varies  somewhat  from  the  latter.  The 
mucous  membrane  lining  the  appendix  is  composed  of  a  deli- 
cate retiform  tissue  containing  numerous  lymphoid  cells  within 


LU 

< 
_l 

Q_ 


ANATOMY.  29 

its  meshes,  and  has  dipping  into  it  a  plentiful  supply  of  solitary 
glands  and  glands  of  Lieberkiihn.  The  latter  glands  vary 
much  in  size  and  number  and  are  often  entirely  absent.  As  a 
rule,  the  retiform  tissue  is  lined  with  a  basement  membrane  on 
which  are  found  columnar  epithelial  cells  covered  with  clusters 
of  various  micro-organisms.  Between  the  mucous  and  submu- 
cous coats,  a  thin  layer  of  circular  muscular  fibers  may  be  dis- 
tinguished, forming  the  muscularis  mucosse.  The  submucosa  is 
formed  of  areolar  tissue,  is  much  denser  than  the  mucous  coat, 
and  contains  numerous  lymphoid  glands.  In  the  submucosa 
are  numerous  small  arteries  and  veins  supplying  the  mucous 
membrane ;  it  generally  contains  a  small  quantity  of  fat. 

From  within  the  caecum  there  is  seen  a  prominence  of  the 
mucous  membrane,  partially  or  completely  surrounding  the 
orifice  of  the  appendix,  due  to  an  increase  of  the  lymphoid 
tissue.  This,  under  certain  circumstances,  may  act  as  a  valve, 
and  thus  favor  occlusion  of  the  orifice. 

The  muscular  coat  consists  of  two  layers.  The  inner  is  a 
thick  layer  of  circular  fibers,  at  times  constituting  fully  one- 
third  the  entire  thickness  of  the  appendiceal  wall.  The  outer 
layer  is  composed  of  longitudinal  fibers.  It  is  not  so  thick  as 
the  inner,  nor  are  the  muscular  fibers  as  regular,  as  at  times 
they  are  bunched  at  certain  points  in  a  manner  similar  to  this 
layer  in  the  csecum. 

Probably  one  of  the  strongest  points  of  evidence  as  to  the 
existence  of  the  longitudinal  muscular  fibers  is  demonstrated 
after  the  removal  of  the  vermiform  appendix,  when  the  organ 
rapidl}'-  shrinks  by  their  contraction,  sometimes  one-third  of 
its  original  length.  The  circular  fibers  possess  the  same  power, 
for  when  the  appendix  has  been  incised  to  expose  its  canal 
there  will  be  immediately  noted  a  contraction  of  the  circular 
fibers,-  thus  bringing  the  mucous  lining  into  view. 

The  peritoneal  coat,  or  serous  covering,  of  the  appendix  is 


30  APPENDICITIS. 

similar  to  the  peritoneum  in  general.  Its  extent  in  regard  to 
tlie  appendix  has  alread}^  been  described. 

The  vascular  supply  of  the  right  iliac  fossa  is  derived  from  a 
loop  formed  by  the  anastomosis  of  branches  of  the  superior 
mesenteric,  the  right  colic,  the  ileo-colic,  and  the  middle  colic 
arteries ;  from  this  loop  secondary  loops  are  given  off  and  from 
these  are  derived  the  arteries  to  the  appendix  and  to  the  ileo- 
csecal  region.  The  branch  to  the  appendix,  the  appendicular 
artery,  passes  along  the  free  edge  of  the  meso-appendix,  if  that 
structure  is  present.  In  the  absence  of  the  meso-appendix,  the 
artery  usually  passes  beneath  the  peritoneal  coat  of  the  appen- 
dix. In  exceptional  cases  the  artery  may  pass  directly  to  the 
tip  of  the  appendix,  in  which  instances  it  will  not  give 
off  branches  until  it  has  entered  the  submucosa. 

In  the  female,  at  times,  there  is  an  additional  supply  of 
blood  brought  to  the  appendix  through  the  folds  of  the 
appendiculo-ovarian  ligament.  The  lymphatics  of  the  appen- 
dix pass  to  a  chain  of  glands  in  the  angle  formed  by  the 
junction  of  the  appendix  with  the  caecum.  The  lymphatics 
may  empty  into  those  of  the  ovary  by  passing  along  the 
appendiculo-ovarian  ligament,  in  this  way  forming  a  com- 
munication between  the  appendix  and  the  ovary. 

The  nerves  of  the  appendix  are  derived  from  the  superior 
mesenteric  plexus  of  the  sympathetic,  the  branches  of  this 
plexus,  which  accompany  the  ileo-colic  artery,  sending  filaments 
to  the  appendix.  As  this  plexus  gives  numerous  twigs  to  the 
small  intestine,  it  is  easily  explained  why  pain,  due  to  disease 
of  the  appendix,  may  be  referred  to  the  whole  abdomen  or  to 
any  region  of  it. 


DIVIDED'i 


Plate  V 


End 

white    ba 

leading 

append 


Appendix 


Back  View  of  Caecum,  with  appendix  attached,  the  latter  covered 
by  serous  coat  of  Caecum.  The  illustration  shows  the  difficulty  encoun- 
tered in  the  removal  of  an  adherent  appendix 


ETIOLOGY. 

The  earlier  writers  on  appendicitis  usually  held  that  the 
main  cause  of  this  affection  was  the  presence  of  a  foreign 
body  in  the  appendix.  Since,  however,  the  true  character  of 
the  disease  has  become  known,  the  presence  or  absence  of  a 
foreign  body,  such  as  a  cherry-stone,  a  grape-seed,  etc.,  has 
played  little  part  as  an  setiologic  factor.  Two  classes  of  causes 
of  appendicitis,  the  predisposing  and  the  exciting,  are  at  present 
recognized. 

Predisposing  Causes. — Among  these  the  anatomic  structure 
of  the  appendix  must  be  considered,  because  its  liability  to 
variations,  in  position  and  size,  is  probably  one  of  the  principal 
causes  of  the  affection.  The  appendix,  functionless  and  unde- 
veloped, is  a  narrow,  musculo-membranous  tube,  lined  with 
mucous  membrane,  ending  in  a  blind  extremity  having  a 
common  orifice  of  entrance  and  exit ;  its  blood-supply  is 
limited,  consisting  of  one  small  artery,  with  no  anastomoses  to 
make  up  for  the  deficiency  of  suppl}^ ;  it  is  an  organ  of  low 
vitality  on  account  of  the  retrograde  metamorphosis  it  is 
undergoing  in  the  process  of  evolution ;  it  is  rich  in  lymphoid 
tissue,  a  fact  that  vastl}'  increases  its  absorptive  powers,  and 
when  attacked  by  inflammation  is,  therefore,  more  liable  to 
progressive  destructive  processes.  If  the  appendix  hold  a 
pendent  position,  there  will  necessarily  be  more  resistance 
offered  to  its  efforts  to  empty  itself  of  any  material  lodging 
in  it.  If  it  lie  in  a  position  in  which  gravity  can  pla}^  a  part 
in  the  discharge  of  the  contents,  there  will  be  correspondingly 
less  liability  to  disease.  The  attachment  of  the  meso-appendix, 
together  with  its  length,  also  act  as  factors  of  some  moment. 

31 


32  APPENDICITIS. 

If  the  mesentery  be  long,  the  tube  will  probably  be  straight 
and  not  subject  to  twists  and  kinks.  If,  on  the  other  hand, 
the  meso-appendix  be  short,  the  organ  will  always  be  curved 
on  itself  and  at  times  twisted,  thus  favoring  the  retention  of 
any  material  that  may  have  become  lodged  within  it.  These 
anatomic  conditions  predispose  the  appendix  to  catarrhal  in- 
flammation, producing  infiltration  of  the  submucous  layer 
resulting  in  thickening,  which  impairs  appendicular  peristalsis 
and  also  interferes  w^ith  free  drainage. 

A  marked  predisposing  factor  in  recurring  inflammation  of 
the  appendix  is  the  fact  that  it  has  already  been  the  seat 
of  disease.  In  the  apparent  recovery  from  the  first  attack, 
the  mucous  membrane  of  the  appendix  undergoes  a  healing 
process  by  which  the  lumen  of  the  organ  is  constricted  either 
at  the  orifice  or  at  points  along  its  length.  If  these  con- 
strictions completely  close  the  lumen  at  any  part,  they  must, 
of  course,  prevent  the  egress  of  any  material  that  may  have 
lodged  beyond  them.  Even  if  not  entirely  closing  the  lumen, 
the  constrictions  are  liable  to  act  as  hindrances  to  the  drain- 
age of  the  organ  and  to  the  expulsion  of  any  contents,  and 
thus  there  will  be  retained  in  the  cavity  a  nidus  for  further 
trouble.  While  it  is  true  that  these  constrictions  may  be 
thought  to  possess  the  power  of  preventing  the  ingress  of 
foreign  material,  yet  it  must  be  acknowledged  that  there  is 
greater  liability  to  the  ingress  of  material  than  to  its  egress, 
owing  to  the  great  difference  between  the  propelling  force  of 
the  bowel  and  the  repelling  force  of  the  diseased  and  weak- 
ened appendix. 

In  a  very  few  cases,  it  is  probable  that  the  cicatricial  process 
extends  along  the  whole  length  of  the  appendicular  canal,  in 
this  way  entirely  obliterating  its  lumen,  and,  consequently, 
absolutely  preventing  further  attacks  of  the  disease.  The 
number  of  cases  in  which  this  occurs  is,  however,  so  small 
that  it  may  be  set  aside. 


.ETIOLOGY.  33 

Mucous  membranes  throughout  the  body,  e.g.,  of  the  throat, 
bladder,  intestinal  tract,  stomach,  etc.,  are  liable  to  a  catarrhal 
inflammation,  and  there  seems  no  good  reason  for  believing 
that  the  mucous  membrane  of  the  appendix  is  an  exception  to 
the  rule.  The  same  causes  that  are  effective  in  the  production 
of  catarrhal  inflammations  elsewhere,  are  probably  equally 
active  in  the  appendix.  While  in  other  localities  they  may 
provoke  no  serious  results,  they  cause  disastrous  lesions  in  the 
appendix. 

Age  is  a  predisposing  cause.  Although  the  disease  is  most 
common  in  those  between  the  ages  of  ten  and  thirty,  about 
15  per  cent,  of  all  cases  occur  in  persons  under  fifteen  years. 
The  youngest  patient  in  whom  I  met  with  the  disease  was  not 
two  years  of  age,  and  the  oldest  seventy.  An  explanation  for 
this  marked  susceptibility,  up  to  adolescence,  may  be  found  in 
the  disturbances  of  the  gastro-intestinal  tract,  so  frequently 
induced  by  indiscretions  in  diet. 

As  to  sex,  males  are  much  more  prone  to  attacks  of  appen- 
dicitis than  females.  There  is  but  one  reasonable  explanation 
for  this,  viz.,  the  fact  that  females  are  supposed  to  have  a 
greater  blood-supply  than  the  males,  both  in  actual  quantity 
and  in  proportion  to  the  size  of  the  appendices  in  the  two 
sexes.  Clado  has  described  a  fold  of  peritoneum  extending 
from  the  appendix  to  the  ovary,  the  appendiculo-ovarian  liga- 
ment, which  carries  a  blood-vessel  to  the  appendix.  This, 
together  with  the  fact  that  the  appendix  of  the  female  is 
smaller  than  that  of  the  male,  may  account  for  the  compara- 
tively small  per  cent,  of  attacks  among  women  and  girls. 

It  is  not  probable  that  either  constipation  or  diarrhoea  play 
a  very  important  role  in  the  causation  of  appendicitis,  as 
statistics  have  shown  that  the  large  majority  of  cases  have 
a  normal,  condition  of  the  bowels  prior  to  and  during  an 
attack. 

3 


34  APPENDICITIS. 

When  tuberculosis,  secondary  to  the  involvement  of  the 
caecum,  is  more  pronounced  in  the  appendix,  it  is  likely  to 
be  followed  by  a  result  similar  to  that  of  acute  perforative 
appendicitis. 

I  have  had  cases  due  to  exposure  to  cold  and  wet.  In  one 
the  attack  was  provoked  by  taking  a  cold  shower  after  coming 
out  of  a  warm  bath,  another  was  the  result  of  wet  feet,  and 
a  third  from  being  chilled  by  lying  in  a  cold  room  shortly 
after  a  heavy  meal. 

I  believe  tj'-phoid  fever  to  be  one  of  the  remote  causes  in 
the  production  of  appendicitis.  The  appendix  contains  many 
solitary  glands  which  at  times  are  the  seat  of  typhoid  ulcers, 
and,  as  a  result  of  the  cicatricial  contraction  of  these  ulcerated 
patches,  obstruction  to  the  lumen  of  the  appendix  occurs. 

In  certain  cases  of  chronic  appendicitis,  developed  post- 
typhoid, I  have  been  unable  to  elicit  a  history  of  previous 
acute  intestinal  disturbance.  Yet  in  these  I  have  found  a 
train  of  symptoms — intestinal  dyspepsia,  vague  pains  in  the 
abdomen,  etc.,  the  origin  of  which  was  traced,  without  doubt, 
to  an  attack  of  typhoid  fever  that  had  occurred  months  or 
years  previous.     This  is  illustrated  in  the  following  case : — 


Miss  I.  M.  W. ,  first  troubled  with  mucous  discharge  from  bowel  in  the 
summer  of  1889,  when  she  had  an  illness  called  tj'phoid  fever,  attended  by 
frequent  watery,  and  in  some  instances,  bloody  discharges.  Was  confined  to 
bed  about  three  weeks.  Tedious  recovery.  Since  this  illness  she  has  been 
subject  to  attacks  of  catarrhal  enteritis,  never  escaping  for  more  than  four 
months,  although  well  during  that  time.  These  attacks,  which  could  be 
traced  to  cold,  unusual  exertion,  sea-sickness,  etc.,  were  less  frequent  in  the 
autumn  and  early  winter,  after  the  change  of  air  and  rest  during  the  summer. 
Two  years  ago  in  June  she  had  a  persistent  attack  lasting  several  weeks. 
Vague  pains  were  present  in  right  iliac  fossa  and  a  distinctly  enlarged  and 
tender  appendix  could  be  made  out  on  palpation. 

Operation.  No  adhesions  ;  the  appendix  contained  pus,  and  was  indurated. 
The  mucosa  and  submucosa  were  thickened,  and  showed  marked  evidences  of 
chronic  catarrhal  inflammation. 

Recovery  followed  with  total  disappearance  of  symptoms. 


ACUTE   APPENDICITIS. 

Mrs.  A.  G.,  aged  thirty-three,  was  admitted  to  the  Grerman  Hospital, 
May,  1896,  with  the  following  history :  Ten  days  previously  she  had  been 
suddenly  seized  by  sharp  pains  in  her  right  side,  attended  by  vomiting.  The 
abdominal  wall  was  rigid  and  markedly  tender  on  pressure  over  the  region  of 
the  appendix.  Constipation  was  present.  The  vomiting  lasted  for  two  days, 
but  the  pain,  tenderness,  and  rigidity  continued  for  one  week,  gradually 
decreasing  meanwhile. 

On  date  of  admission  her  temperature  was  101°  ;  pulse  rate  112  ;  stomach 
not  irritable.  Her  abdomen  was  slightly  swollen,  and  in  her  right  iliac  fossa 
close  to  the  iliac  spine  was  a  mass  the  size  of  an  orange,  which  was  7iot  pain- 
ful on  pressure,  though  moderate  tenderness  existed  upon  deep  palpation. 
Appendicitis  was  diagnosed,  but  on  account  of  the  absence  of  pain  and  tender- 
ness in  the  mass  over  the  appendix,  which  seemed  an  anomalous  condition, 
operation  was  deferred  for  one  day.  Her  temperature,  however,  steadily  rose 
to  J  03°,  and  immediate  surgical  interference  was  considered  necessary. 

Section  of  the  abdominal  wall  showed  the  muscles  infiltrated.  The 
parietal  peritoneum  was  closely  adherent  to  a  mass  which  was  composed  of 
omentum,  and  the  appendix  bound  together  by  organized  exudate.  No  pus 
was  found.  The  appendix  was  freed,  tied  off,  and  removed,  and  upon  exami- 
nation proved  to  contain  a  black  pin,  which  had  entered  the  canal  point  first. 
This  case  is  particularly  interesting  from  the  fact  that,  despite  the  mass,  pain 
and  tenderness  were  not  marked.  It  also  illustrates  that  in  the  absence  of 
great  local  tenderness,  a  diagnosis  of  pus  in  or  about  the  appendix  is  not 
warrantable. 


^ 


i 


Plate  VI 


Showing  Appendix   containing    Pin 

(Twice    natural    size) 


ETIOLOGY.  37 

Another  of  the  predisposing  causes  is  the  fact  that  the  base- 
ment membrane  of  the  mucous  lining  of  the  appendix  is  almost 
alwaj'S  the  seat  of  clusters  of  micro-organisms  that  are  ever 
ready  for  an  opportunity  to  attack  the  structure  of  the  organ 
and  thus  set  up  an  acute  inflammatory  condition.  The  role 
played  by  micro-organisms  will  be  more  fully  discussed  under 
the  chapter  on  pathology. 

Exciting  Causes. — It  is  probable  that  all  cases  of  appendicitis 
are  directly  due  to  the  invasion  of  micro-organisms.  This  may 
occur  independently  of  any  other  change  in  the  region  of  the 
appendix  or  of  the  intestinal  canal,  or  it  may  be  directly  due 
to  disturbances  brought  about  by  several  causes.  For  instance, 
changes  in  the  blood-supply  of  the  appendix,  the  result  of  a 
bend  or  twist,  may  so  lower  the  little  resisting  force  the  organ 
possesses  that  the  micro-organisms  are  given  full  play.  Dis- 
turbances of  digestion  are  claimed  by  many  authors  to  be 
exciting  causes.  Fowler  holds  that  these  play  a  very  unim- 
portant part.  Talamon,  on  the  other  hand,  thinks  that  per- 
istalsis, induced  by  the  presence  in  the  intestinal  tract  of 
irritating  material,  is  liable  to  engage  a  stercoral  calculus 
within  the  orifice  of  the  appendix,  and  that  this  gives  rise  to 
symptoms  found  in  the  first  stages  of  the  disease.  It  is 
claimed,  also,  that  this  erratic  peristalsis  awakens  the  micro- 
organisms to  a  more  virulent  condition,  thus  enabling  them 
to  inaugurate  more  easily  inflammatory  conditions.  I  am 
positive  that  acute  indigestion  plays  a  very  important  role  in 
the  aetiology  of  appendicitis.  I  have  seen  this  demonstrated  so 
often  that  I  express  this  opinion  unhesitatingly.  The  intro- 
duction of  foreign  substances  into  the  lumen  of  the  appendix, 
such  as  cherry-  or  date-stones,  pins,  etc.,  is  an  infrequent  cause 
of  appendicitis.  It  is  true  that  seeds,  pits,  pins,  etc.,  have  been 
found  in  the  appendix.  The  case  of  Mrs.  A.  G.  (page  36,  Plate 
VI)  illustrates  this,  but  it  is  probable  that  in  the  large  majority 


38  APPENDICITIS. 

of  these  cases  the  supposed  seeds,  etc.,  were  fsecal  concretions,  as 
these  concretions  bear  a  very  striking  resemblance  to  such 
foreign  bodies. 

Fsecal  concretions,  though  not  the  direct  cause,  are  probably 
the  most  frequent  exciting  cause  of  acute  affections  of  the  appen- 
dix. It  was  formerly  the  accepted  opinion  that  fsecal  concre- 
tions, having  formed  in  the  small  intestine,  migrated  into  the 
appendix  and  there  set  up  inflammation  with  its  disastrous  con- 
sequences. This  view  is  no  longer  held.  The  course  of  events 
seems  rather  to  be  as  follows :  A  small  normal  fsecal  particle 
being  carried  into  an  appendix,  the  mucous  membrane  of 
which  is  inflamed,  is  there  retained,  the  swollen  membrane,  the 
inflamed  muscle,  and  the  abnormal  adhesions  inside  the  appen- 
dix preventing  its  egress.  The  concretion  is  gradually  increased 
in  size  by  concentric  layers  of  mucous  and  purulent  products 
deposited  on  it.  As  it  grows  the  appendix  is  dilated  (Fig.  1). 
At  first  no  injurious  eflect  may  be  evident.  When,  however,  the 
concretion  has  attained  considerable  size  it  becomes  directly 
harmful  to  the  mucous  membrane,  causing  then  pressure- 
necrosis  and  gradual  perforation  of  all  the  histologic  layers  of 

the  appendix.     (In  the  case  of  Wm. ,  herewith  presented 

[Plate  VII],  perforation  was  imminent,  the  walls  of  the  appen- 
dix having  become  so  friable  that  they  parted  upon  the 
slightest  pressure.) 

The  fact  that  the  large  concretions  often  found  could  not 
possibly  have  been  introduced  without  tearing  the  appendiceal 
opening,  is  sufficient  proof  of  the  growth  of  the  concretions 
after  their  lodgment  in  the  appendix. 

We  conclude,  therefore,  that  while  the  formation  of  coproliths 
stands  in  close  relation  with  diseases  of  the  vermiform  appen- 
dix, they  are  not  the  primary  cause,  but  rather  a  consequence 
of  the  disease.  They  develop  when  an  appendicitis  already 
exists,  and  only  afterward  assume  dangerous  tendencies ;  they 


CHEONIC  APPENDICITIS. 

Wm.  ,  age  thirtj'-six.     Had  always  enjoyed  good  health  ;  had  been  a 

member  of  the  crew  when  a  student  at  Hai-vard  College. 

On  November  15,  1895,  was  seized  suddenly,  after  a  long  ride  in  a  cold, 
damp  wind,  with  what  seemed  at  first  to  be  a  severe  attack  of  indigestion. 
Within  a  few  hours  pain  became  intense,  with  marked  tenderness  on  pressure 
over  the  appendix,  soon  followed  by  general  abdominal  distention.  Constipa- 
tion present.  Calomel  and  ounce  doses  of  Rochelle  salts  were  given  by  mouth, 
followed  by  an  enema  of  Epsom  salts  (two  ounces  in  hot  water).  After 
copious  evacuations  the  tenderness  subsided,  and  in  a  few  days  he  was  up  and 
attending  to  business,  though  not  entirely  well. 

On  December  15th,  after  a  heavy  meal,  a  second  attack  was  excited,  which 
likewise  subsided  upon  free  purgation,  leaving  him  in  the  same  condition  as 
before. 

On  January  7th  a  third  attack  occurred,  which  subsided  but  slightly  after 
above  treatment.     Surgical  interference  was  then  decided  upon. 

The  operation  (performed  January,  1 896)  was  complicated  by  a  very  fat 
and  muscular  abdominal  wall.  Appendix  pointed  N.  and  lay  behind  the 
caecum,  which  was  tied  down  ;  meso-appendix  contained  a  small  purulent  collec- 
tion. Very  fat  and  long  omentum  and  meso-colon  ;  caecum  perforated  ;  per- 
foration closed  under  most  unfavorable  conditions.  The  appendix,  which  con- 
tained a  large  fsecal  concretion,  giving  it  the  appearance  of  the  fundus  of  a  gall 
bladder,  was  removed.  It  was  ulcerated  ofi"  the  caecum.  Iodoform  gauze 
drainage  was  carried  down  to  and  covering  the  sutures  in  caecum,  in  case  the 
sutures  should  not  hold. 

Recovery  uninterrupted.  In  protecting  the  peritoneum  and  in  the  technic 
of  the  peritoneal  toilet  in  this  operation,  ninety  pieces  of  gauze  were  used. 
This  case  is  rather  exceptional,  in  that  the  gangrene  occurred  on  the  proximal 
side  of  the  concretion. 


40 


Plate  VI 1 


Appendix  ulcerated 
off  caecum 


Tissue  at  lower  end  exceedingly 
friable,  slight  pressure  causing 
it  to  break  with  extrusior\  of 
coprolithi 


CHEONIC   APPENDICITIS. 

F.  Zollers,  age  twenty-one.    First  attack :  was  seized,  after  eating,  witli 
acute  abdominal  pain,  vomiting,  etc.     Cardinal  symptoms  marked. 

Operation  was  performed  on  the  seventh  day  of  the  disease  ;  a  large  quan- 
tity of  pus  was  present.  Appendix  was  perforated  in  two  places,  at  and  near 
the  tip.  It  contained  near  the  middle  a  large  faecal  concretion.  In  the  plate 
this  concretion  has  been  shown  by  cutting  the  appendix  at  that  point. 
Patient  died  two  weeks  after  operation.  Autopsy  showed  field  of  operation 
clean.  Gangrenous  patch  two  inches  in  length,  involving  half  the  circumfer- 
ence of  a  loop  of  ileum  occupying  the  pelvis.  Gangrenous  patch  perforated, 
allowing  escape  of  small  quantity  of  fascal  matter  into  pelvis.  No  pus  was 
found  in  the  pelvis.  No  connection  between  disease  of  ileum  and  field  of 
operation.  The  involved  coil  of  ileum  enveloped  in  mass  of  exudate.  The 
exudate  evidently  the  result  of  the  peritoneal  infiammation  which  had  ex- 
tended from  the  appendix  by  contiguity. 


42 


Plate  VI  i 


Proximal  end 


Coprolith  exposed 


;/        Iriflamed  and  tliickened 
meso-appendix 


\  Perforation  at  tips 


Perforation 


iETIOLOGY. 


43 


then  serve  as  pathologic  factors  by  mere  interference  with  drain- 
age, thereby  preventing  the  emptying  of  the  appendix.  Again, 
by  constricting  the  lumen,  and  causing  pressure  and  interfer- 
ence with  the  circulation,  they  favor  gangrene  of  the  organ  on 
the  distal  side  of  the  concretion  (see  case  of  F.  Z.,  Plate  VIII). 
Moreover,  by  inducing   pressure-necrosis,  they  allow   micro- 


FiG.  1. — Showing  Situation  of  Fsecal  Concretion  and  Dilatation  of  the  Appendix  in  the 

Case  of  Win.  ,  Before  Occurrence  of  Gangrene  and  Sloughing  of  Appendix, 

See  Plate  VII. 


organisms  to  invade  the  structure  of  the  organ,  and  thus  set  up 
the  true  inflammatory  disease.  This  pressure-necrosis  also  in- 
duces greater  probability  of  a  perforation.  It  is  a  well-established 
fact,  demonstrated  by  abdominal  section  performed  for  other  dis- 
eases, that  feecal  concretions  are  often  found  in  perfectly  normal 
appendices,  and  it  has  also  been  proved  that  we  may  have 


44  APPENDICITIS. 

acute  inflammation  of  the  appendix,  and  even  perforation  and 
gangrene,  without  the  presence  of  fsecal  concretions  or  inspis- 
sated mucus.  In  these  cases  it  is  probable  that  there  has  been 
some  interference  with  the  circulation  or  with  the  activity  of 
the  expelling  force  of  the  organ. 

To  sum  up :  I  believe  that  there  are  many  factors  that  pre- 
dispose to  appendicitis,  among  them  being  the  anatomic  struc- 
ture of  the  appendix,  its  position,  its  inadequate  drainage, 
the  length  of  the  appendix  and  of  the  meso-appendix,  a  pre- 
vious attack  of  local  inflammation,  tj^phoid  fever,  age,  and 
sex.  I  believe  that  all  cases  of  appendicitis  are  directly  due  to 
the  invasion  of  certain  micro-organisms ;  that  fsecal  concretions 
act  as  a  pathologic  factor  by  stenosis  of  the  lumen  of  the 
appendix,  or  by  interference  with  the  circulation,  or  by  setting 
up  pressure-necrosis ;  that  there  are  cases  in  which  the  fsecal 
concretions  play  no  part  in  the  cause  of  the  affection ;  that 
foreign  bodies,  such  as  grape-seeds,  cherry-stones,  etc.,  may,  at 
times,  be  the  direct  cause  of  the  invasion  of  the  micro-organisms, 
but  that  this  rarely  occurs. 


PATHOLOGY. 

We  recognize  four  stages  in  the  pathology  of  appendicitis ; 
these  Fowler  has  given  as  follows : — 

1.  Endo-appendicitis,  in  which  there  is  more  or  less  inflam- 
mation of  the  mucous  membrane  and  sub-mucosa. 

2.  Parietal  appendicitis,  in  which  the  inflammation  attacks  the 
interstitial  or  intermuscular  tissue  of  the  body  of  the  appendix. 

3.  Peri-appendicitis,  in  which  inflammation  attacks  the  serous 
covering  of  the  appendix,  being  limited  by  adhesions  to  that 
portion  of  the  peritoneum  between  the  appendix  and  the 
serous  surfaces  immediately  adjoining. 

4.  Para-appendicitis,  in  which  the  inflammation  attacks  the 
tissues  in  relation  with  the  appendix.  In  the  last  stage  we 
find  pus  formation  either  localized  by  the  limiting  adhesions 
formed  during  the  third  stage,  or  general  involvement  of  the 
peritoneum,  etc. 

It  must  be  remembered  that  these  stages  are  not  marked  by 
distinct  lines  of  separation,  because  any  one  of  them  may  be 
absent  as  a  distinct  stage,  or,  again,  they  may  so  merge  into 
each  other  that  it  is  impossible  to  distinguish  between  them. 

In  an  attack  of  appendicitis,  the  primary  condition  is 
catarrhal  inflammation.  The  changes  are  similar  to  those 
of  inflammation  of  mucous  membranes  in  general.  We 
first  notice  a  rapid  shedding  of  the  epithelium.  The  reti- 
form  tissue  forming  the  groundwork  of  the  mucous  mem- 
brane becomes  the  seat  of  an  infiltration  of  leucocytes ;  while 
many  of  the  crypts  of  Lieberkiihn  become  obliterated  from 
the  pressure  exerted  by  the  infiltrate.  This  is  followed  by 
destruction  of  the  basement  membrane  and  increase  of  the 

45 


46  APPENDICITIS. 

leucocytal  infiltration,  the  mucosa  taking  the  form  of  a 
dense  cellular  layer  with  a  raw  internal  surface.  Numerous 
pockets  containing  degenerating  remains  of  epithelial  cells  are 

seen  (see  case  of  Miss  B ,  Plate  IX).     In  the  lumen  will  be 

found  leucocytes,  granular  debris,  mucus,  pus,  etc.,  often  molded 
into  a  definite  mass  by  the  muscular  contractions  of  the  organ. 

The  outcome  of  the  attack  depends  upon  several  important 
factors :  1.  Drainage  of  the  organ.  2.  The  character  and 
virulence  of  the  micro-organisms  present,  3.  The  presence 
or  absence  of  fsecal  concretions  or  foreign  bodies. 

If  the  appendix  lies  in  such  a  position  that  gravity  favors 
drainage,  the  products  of  the  inflammatory  process  may  be 
readily  discharged,  followed  by  amelioration  of  all  the  symp- 
toms. If,  however,  the  organ  holds  a  position  in  which  gravity 
opposes  drainage,  there  may  be  retention  of  inflammatory 
products,  with  consequent  increased  inflammation.  If  the 
lumen  remains  unobstructed,  the  debris  may  be  expelled  by 
the  peristaltic  contractions  of  the  organ.  There  is  no  doubt 
in  my  mind  that  the  peristaltic  contraction  plays  an  import- 
ant part  in  appendicitis,  both  as  regards  the  causation  and 
the  result  of  an  attack.  In  those  cases  in  which  drainage  is 
perfect,  we  generally  find  apparent  recovery,  and  the  reverse  is 
true  if  there  is  interference  with  the  drainage. 

The  micro-organisms  found  in  the  first  stage  play  a  very 
important  part  in  respect  to  the  outcome  of  an  attack,  both  by 
their  species  and  by  the  virulence  they  individually  possess. 
Thus,  if  the  colon  bacillus  {bacillus  coli  communis)  is  present, 
unassociated  with  any  other  form,  and  if  this  bacillus  is  not 
virulent,  the  attack  may  terminate  favorably.  If  we  find  the 
streptococcus  present,  we  may  look  for  a  less  favorable  result. 
Generally  speaking,  the  association  of  two  or  more  forms  of 
micro-organisms  means  a  more  rapid  course  and  one  of  greater 
intensity. 


Miss  B.,  aged  twenty  years,  was  admitted  to  the  hospital  November  16, 
1895,  with  a  typical  attack  of  acute  aijpendicitis.  Immediate  operation  was 
performed. 

Operation  revealed  an  acutely  inflamed  appendix  which  was  very  tense  to 
the  touch.  The  meso-appendix  was  also  highly  inflamed.  The  blood-vessels 
were  engorged  and  prominent.  After  opening  the  appendix  masses  of  debris, 
mucus,  pus,  and  gangrenous  tissue,  having  a  very  bad  odor,  were  exposed. 
The  mucous  membrane  was  rough  and  presented  nearly  all  shades  of  color. 

Recovery  rapid  and  uninterrupted. 


48 


Plate  IX 


Fig.  I 


I  qf  lamed 
rneso-appendix  * 


---Blood  vessels 


Fig.  2 


Meso-appeqdix. 


^iS 


Appendix  oper\ed 
sf\owir;g  gangrenous 
and  purulent  coqtents 


PATHOLOGY.  49 

The  action  of  these  micro-organisms  is  greatly  influenced  by 
the  drainage  of  the  organ,  and  by  the  presence  or  absence  of 
fecal  concretions  or  foreign  bodies.  If  fiaecal  concretions  or 
foreign  bodies  are  present,  they  are  liable  to  block  up  the 
lumen  of  the  organ  and  thus  induce  the  retention  of  inflam- 
matory products.  In  this  case  the  process  will  immediately 
proceed  to  the  second  stage,  and  attack  the  parietes  of  the 
organ. 

If  the  appendix  recovers  after  the  catarrhal  process  has 
been  in  force,  there  will  be  a  replacement  of  the  destroyed 
mucous  membrane  by  a  tissue  rich  in  cells.  We  often  find  a 
cicatricial  condition  in  this  healing  process  of  the  mucous 
membrane,  that  in  places  narrows  the  lumen  of  the  canal,  and 
at  times  obliterates  the  entire  cavity  of  the  organ.  Ribbert 
makes  the  interesting  statement  that  among  400  post-mortem 
examinations  of  the  appendix,  he  found  99  (25  per  cent.)  in 
which  there  was  partial  or  complete  occlusion  of  the  lumen  of 
the  appendix  (see  case  of  H.  C.  D.,  Plate  X,  also  Plate  XI).  Of 
the  99  obliterations  16  were  found  to  be  total.  There  is  in 
these  cases  generally  a  disappearance  of  the  normal  glands,  and 
the  walls  of  mucous  membrane  grow  together,  although  the 
remaining  layers  of  the  organ  remain  normal. 

As  shown  by  the  statistics  of  Ribbert,  there  may  be  in  a 
small  percentage  of  cases  of  disease  of  the  appendix,  if 
checked  in  the  first  stage,  perfect  recovery  by  the  total  oblit- 
eration of  the  lumen.  This  process  of  obliteration  may  begin 
at  any  point  and  extend  in  either  direction  until  complete,  or, 
as  most  frequently  happens,  it  may  start  at  the  tip  of  the  organ 
and  proceed  toward  the  base,  in  this  manner  expelling  before 
it  any  inflammatory  products. 

If,  however,  the  process  begins  at  any  point  but  the  tip,  we 
shall  almost  always  find  mucus  and  fsecal  matter  confined 
within  a  closed  cavity.  The  results  of  this  confined  material 
4 


50  APPENDICITIS. 

may  be  determined  by  one  of  several  conditions.  There  is 
generally  extension  of  the  inflammation  into  the  parietal 
layers  of  the  organ,  in  which  case  it  will  burrow  through  the 
walls  and  cause  perforation ;  or  the  mass  may  interfere  with 
the  circulation,  thus  causing  gangrene  and  perforation  (see  case 
of  C.  J.  E.,  Plate  XI) ;  or  by  pressure  it  may  cause  necrosis  of 
the  walls  of  the  organ,  ending  in  perforation.  If  the  cellular 
tissue-layer  that  has  replaced  the  mucosa  is  exceptionally  dense, 
we  shall  find  the  material  retained  within  the  walls.  As  the 
amount  of  the  debris  increases,  the  walls  of  the  appendix  dilate 
to  a  remarkable  degree  and  give  to  the  organ  various  shapes, 
depending  upon  the  number  and  position  of  the  constrictions 
and  upon  the  amount  of  debris  contained  within  the  lumen. 
In  one  instance  I  found  the  appendix  distended  to  such  an 
extent  that  I  at  first  thought  it  was  a  small  ovarian  cyst.  In 
this  case  the  constriction  was  at  the  mouth  of  the  appendix. 
In  a  second  instance  there  was  a  constriction  at  the  mouth 
and  another  about  the  middle  of  the  organ,  with  an  hour- 
glass-shaped bulging  of  the  walls.  In  this  connection  the 
following  case  may  be  of  interest : — 

LARGE  CYSTIC  APPENDIX. 

Miss  C. ,  twenty-five  years  of  age,  had  had  two  attacks  of  appendicitis,  the 
last  being  very  severe  and  complicated  by  general  peritonitis.  Temporary 
recovery  was  secured  under  saline  treatment. 

Operation  showed  a  cystic  appendix  the  size  of  a  small  orange,  and  adher- 
ent both  to  neighboring  coils  of  bowel  and  to  the  right  broad  ligament.  The 
appendix  was  occluded  at  proximal  end  one-quarter  of  an  inch  from  its  caecal 
attachment,  and  contained  albuminous  material. 

Recovery  was  uneventful. 

At  times,  instead  of  recovering,  or  instead  of  progressing 
into  the  parietal  stage,  the  catarrhal  state  lapses  into  a 
chronic  condition.  There  is  marked  infiltration,  with  decided 
thickening   and  rigidity  of  the   walls  of  the   organ,  due   to 


CHEONIC  APPENDICITIS. 

H.  C.  D. ,  physician,  has  presented  the  following  report : — 

On  July  20,  1894,  I  was  awakened  by  a  feeling  of  discomfort  in  the 
abdomen,  located  chiefly  around  the  umbilical  region.  It  gradually  grew 
worse  until  I  had  severe  pain  in  this  region.  I  took  one-fourth  of  a  grain  of 
morphia,  which  gave  me  relief.  I  was  able  to  get  up  and  attend  to  my  work 
two  hours  afterward.  There  was  some  soreness,  discomfort,  and  tenderness  on 
deep  pressure  over  the  region  of  the  appendix.  In  four  or  five  days  I  was 
feeling  very  much  better. 

I  remained  apparently  well  until  September  20th,  when  I  had  a  similar 
attack  which  was  more  severe  and  confined  me  to  bed  for  six  hours.  Vomited 
freely,  principally  bilious  matter.  After  being  purged  freely  by  citrate  of 
magnesia  I  was  relieved,  but  the  soreness  over  the  appendix  remained  for  one 
week. 

For  three  months  I  had  perfect  health  and  gained  in  flesh.  On  December 
30th  I  had  another  attack,  accompanied  by  severe  pain  and  distress  in  abdo- 
men ;  vomited  freely  without  any  relief.  Stomach  was  irritable  for  thirty-six 
hours  after  this  ceased.  I  took  a  dose  of  castor  oil,  which  acted  in  four  hours. 
After  the  first  bowel  movement  I  felt  greatly  relieved.  Temperature  ranged 
from  99°  to  10l|°.  This  attack  was  due  to  cold.  After  this  attack  I  was  not 
well.  Had  more  or  less  soreness  over  the  appendix,  attended  with  obstinate 
constipation  and  dyspeptic  symptoms.  At  times  I  had  a  great  deal  of  pain 
in  right  testicle. 

Was  operated  upon  March  26,  1896.     Recovery. 


52 


Plate  X 


Pus  cavity 


Poiqt  of  parti  a 
occlusioq 


hesions  to  coil  of  ileum 
J  sing  acute  flexure 


Pus  cavity 


Orrieqtat  adhesioris 


Fig,  2 


ACUTE  APPENDICITIS. 

C.  J.  E. ,  age  fifty-six,  was  taken  suddenly  ill  on  the  evening  of  July  23, 
1895,  with  severe  abdominal  pain.  Examination  by  attending  physician  dis- 
closed a  distended  abdomen  and  local  tenderness  in  the  right  iliac  region.  Had 
pain  with  persistent  tenderness  over  region  of  appendix.  Grave  a  history  of 
several  similar  attacks  which  had  been  treated  as  ordinary  colic.  The  evening 
of  the  second  day  I  saw  the  patient  and  advised  operation,  which  was  delayed 
for  two  days.  Operation  disclosed  a  very  long  and  gangrenous  appendix  lying 
post-caecal  and  post-colic  ;  perforated  ;  bathed  in  pus  ;  contained  several  faecal 
concretions.  Pus  in  pelvis.  Grlass  and  gauze  drainage  were  used.  Recovery 
followed. 

Remarks. — Patient  the  subject  of  chronic  interstitial  nephritis.  For  two 
days  following  operation  vomiting  and  hiccough  were  persistent. 


54 


.-Fsecal  concretion 


Plate  XI 


.Perforation 


PATHOLOGY.  55 

great  increase  of  the  fibrous  element.  This  thickening  and 
rigidity  prevent  the  collapse  of  the  walls,  hinder  obliteration? 
and  interfere  with  peristaltic  contractions  of  the  organ,  thus 
rendering  difficult  the  expulsion  of  any  inflammatory  products 
present.  The  lining  membrane  continues  as  a  pus-secreting 
granulation-tissue. 

In  the  second  stage  of  the  disease,  there  is  inflammatory 
involvement  of  the  muscular  walls  of  the  appendix,  with 
slight  encroachment  upon  the  serous  covering.  Although 
this  may  be  induced  by  infection  along  the  lymphatics  with- 
out involvement  of  the  mucous  lining  of  the  tube,  it  is 
generally  secondary  to  the  first  stage.  There  is  engorgement 
of  the  organ  with  deposit  of  exudate  in  the  perivascular 
tissue.  The  appendix  is  enlarged,  congested,  and  hard.  We 
often  find  ulcers  in  the  walls,  caused  by  the  pressure  of  the 
exudate  in  the  interstitial  tissues,  extending  into  the  lumen  of 
the  organ  and  by  perforation  soon  communicating  wnth  the 
peritoneal  cavity  (see  case  of  Mrs.  R.,  Plate  XII).  These 
ulcerations  may  also  be  due  to  a  necrotic  process  caused  by 
the  pressure  of  a  fsecal  concretion  or  foreign  body.  The  con- 
cretions are  generally  soft  and  friable.  They  may  harden, 
however,  as  the  disease  progresses,  on  account  of  the  deposi- 
tion upon  their  surfaces  of  lime-salts,  usually  the  carbonate 
and  the  phosphate  of  lime.  As  the  pressure  increases,  the 
epithelium,  the  mucous  membrane,  the  submucosa,  the  mus- 
cular layer,  and,  finally,  the  peritoneum  are  in  turn  destroyed, 
and  the  pressing  mass  is  expelled  into  the  abdominal  cavity. 
Perforation  caused  in  this  way,  however,  cannot  always  be 
ascribed  to  an  ulcerative  process,  as  evidences  of  inflammation 
are  often  absent.  In  these  instances  the  destruction  of  the 
tissues  is  due  to  an  atrophic  condition  produced  by  pressure. 

Gangrene  may  be  caused  by  interference  with  the  circulation  ; 
by  pressure ;  by  strangulation  due  to  twisting  of  the  appendix. 


56  APPENDICITIS. 

or  by  embolism  of  the  solitary  artery  or  one  of  its  branches. 
In  this  stage  we  often  find  a  rapidly  spreading  phlegmonous 
inflammation  due  to  the  formation  of  pus,  or,  as  demonstrated 
in  the  case  reported  on  page  95,  the  pus  may  be  collected  in 
minute  abscesses. 

In  this  stage  paresis  of  the  appendix  is  often  found  conse- 
quent upon  the  inflammatory  infiltration  of  its  muscular  coats. 
This  paralysis  interferes  with  the  expelling  force  of  the  organ, 
and  thus  gives  the  debris  and  micro-organisms  an  opportunity 
to  collect  in  the  canal  and  hasten  the  process  into  the  third 
stage. 

In  the  third  stage  we  find  the  peritoneal  covering  of  the 
appendix  severely  affected.  There  are  adhesions  between  the 
appendix  and  the  adjacent  serous  surface,  thus  limiting  the  in- 
flammation and,  in  case  of  pus  formation,  forming  a  barrier 
against  infection  of  the  general  peritoneal  cavity  (see  case  of 
M.  S.,  Plate  XIII).  If  these  adhesions  are  strong  and  plenti- 
ful, thus  forming  a  firm  wall  around  the  inflamed  area,  we 
shall  have  the  inflammatory  process  confined  entirely  to  the 
right  iliac  fossa.  The  disposition  of  this  wall  of  adhesions 
plays  an  important  part  in  the  subsequent  treatment  of  the 
disease, — so  far,  at  least,  as  the  removal  of  the  appendix  is 
concerned.  The  adhesions  may  form  between  the  csecum  and 
the  adjacent  coils  of  intestine  and  the  parietal  layer  of  the 
peritoneum  (see  case  of  Mrs.  H.,  Plate  XIV).  In  this  condition 
the  appendix  will  lie  free  in  the  enclosed  area.  In  other  states 
the  appendix  and  part  of  the  csecum  will  be  confined  within 
the  walls  of  adhesion  (see  case  of  M.  T.,  Plate  XV) ;  or  the  base 
of  the  appendix  may  be  outside  the  enclosed  area,  part  of  the 
appendix  forming  a  portion  of  the  wall  and  the  rest  emerging 
into  the  portion  of  the  right  iliac  fossa  that  is  shut  in  by  the 
limiting  membrane.  In  any  of  these  instances,  the  proper 
procedure  in  the  treatment  is  to  remove  the  organ,  even  if  the 


CHRONIC  APPENDICITIS. 

Mrs.  R. ,  age  thirty.  Had  always  been  rather  deUcate,  but  enjoyed  a  com- 
paratively good  degree  of  health  except  for  a  chronic  intestinal  dyspepsia  of 
mild  character  with  occasional  exacerbations.  In  May,  1895,  she  had  an 
attack  of  what  was  believed  to  be  intestinal  indigestion  of  more  than  usual 
severity,  accompanied  by  diarrhoea  and  pain  referred  to  region  of  appendix ; 
recovered  in  a  few  days.  December  7,  1895,  she  was  suddenly  seized  with 
acute  agonizing  pain  in  abdomen,  followed  by  rigidity  of  whole  abdominal  wall 
and  diflFuse  tenderness.  This  condition  yielded  to  the  administration  of  laxa- 
tives and  to  hot  applications  locally.  Nausea  and  vomiting,  which  at  first 
were  persistent,  gradually  subsided,  with  the  tenderness  becoming  localized 
over  the  appendix.     The  temperature  never  rose  above  102°. 

On  the  tenth  day  a  slight  exacerbation  of  pain  was  caused  by  an  indiscre- 
tion in  diet.  Two  hypodermics  of  morphia  were  given  in  the  course  of  the 
attack  of  pain,  to  quiet  nervous  excitement.  Copious  enemata  were  admin- 
istered twice  daily,  and  rectal  feeding  instituted  until  the  stomach  became 
quiet  and  retentive. 

Although  patient  was  recovering  satisfactorily,  operation  for  the  removal 
of  the  appendix  was  decided  upon  and  performed  January  18,  1896. 

The  operation  showed  the  appendix  enlarged,  congested,  and  hard,  and  a 
point  of  beginning  ulceration  near  the  tip.  Upon  opening  the  appendix  the 
mucous  membrane  at  the  base  was  found  much  inflamed  and  thickened,  pre- 
senting superficial  ulcerated  areas.  The  lumen  beyond  the  ulcerated  part  was 
totally  obliterated. 

The  recovery  was  uninterrupted,  and  was  followed  by  decided  improvement 
of  the  old  condition. 


58 


Fig.  I 


Point  of  beginniqg   ulceratiori 


Fig.  2 


Plate  XII 


Inflarqed  aqd  thickened 
mucous  membrane 


Obliterated   lumen 


PATHOLOGY.  59 

wall  has  to  be  broken  through,  for  in  no  other  way  can  we 
assure  ourselves  that  we  have  removed  all  chance  of  subse- 
quent complications. 

At  this  period  there  is  marked  engorgement  of  the  peri- 
vascular tissues,  swelling  and  hardening  of  the  organ.  We 
may  find  dark  and  soft  necrotic  patches  containing  within  the 
tissues  colonies  of  micro-organisms  ready  to  perforate.  Gan- 
grene will  often  be  noticed,  due  to  interference  with  the  cir- 
culation. In  either  the  second  or  third  stage,  as  will  be 
explained  later,  we  are  likely  to  find  necrotic  or  gangrenous 
patches  in  the  meso-appendix,  caused  by  obstruction  of  the 
circulation. 

In  the  fourth  stage,  there  is  involvement  of  the  para-appen- 
dicular  tissues,  associated  with  pus  formation,  which  is  due  to 
direct  invasion  of  pus  through  a  perforated  or  gangrenous 
appendix,  or  to  the  spread  of  the  phlegmonous  inflammatory 
process  along  the  contiguous  tissues.  If,  during  the  third 
stage,  the  course  of  the  inflammation  has  been  slow  enough  to 
allow  nature  to  throw  a  strong  retaining  wall  around  the 
aflected  area,  we  shall  find  the  results  of  this  stage  limited  by 
the  boundary-membrane.  Very  often  the  process  has  been  so 
rapid  in  its  course  that  nature  has  had  no  opportunity  to 
protect  the  surrounding  structures,  and  the  result  is  that  we 
find  involvement  of  the  peritoneum,  generally  in  the  form  of 
a  purulent  inflammation,  with  pus  free  in  the  peritoneal 
cavity  and  in  the  pelvis.  If  the  pus  is  limited  to  the  right 
iliac  fossa  we  may  have  a  period  of  apparent  quiescence  so  far 
as  any  more  extensive  trouble  is  concerned,  or  we  may  find 
the  pus  burrowing  in  almost  any  direction,  or  ending  in 
metastasis  along  the  various  lymphatic  or  blood  channels. 
Thus,  in  the  following  case,  the  history  of  which  has  been 
furnished  by  Dr.  0.  Rath,  the  abscess  had  worked  its  way 
upward  behind  the  liver  and  inward  to  the  vertebral  column. 


60  APPENDICITIS. 

November  25,  1895,  I  was  called  to  see  W.  D.  H.,  physician,  thirtj'--one 
years  old.  He  had  been  sick  since  November  22, 1895,  suffering  from  a  severe 
follicular  tonsillitis.  Previous  history  negative,  with  exception  of  an  attack 
of  pneumonia  during  childhood.  At  first  visit  he  complained  of  severe  pain 
over  the  stomach,  nausea,  loss  of  appetite,  constipation,  and  violent  headache. 
On  examination  found  temperature  102°,  pulse-rate  100,  respiration  26.  No 
action  of  bowels  for  two  days  ;  nausea,  but  no  vomiting.  The  abdomen  was 
much  distended  ;  severe  pain  on  pressure  over  epigastric  region,  with  slight 
pain  and  resistance  on  pressure  in  the  right  iliac  fossa.  Lungs  and  heart 
negative.  Urine  high-colored,  slight  amount  of  albumen,  and  a  few  granular 
casts. 

November  26th  and  27th,  continuous  vomiting  of  biliary  matter.  Vomiting 
was  relieved  by  cocain  and  bismuth  subnitrate.  The  bowels  were  moved  by 
small  doses  of  calomel.  November  28th,  vomiting  ceased.  Condition  about 
the  same,  no  pain  in  right  iliac  fossa,  but  pain  over  epigastrium  as  before. 
Temperature  101°  to  102°,  pulse-rate  90  to  110,  respiration  24.  Patient 
restless ;  no  sleep  except  after  injections  of  morphia  sulph.  Bowels  moved 
only  after  the  administration  of  calomel  or  glycerin  enemata.  This  condition 
continued  until  December  7th,  4  P.  M. ,  when  the  patient  had  a  slight  chill 
followed  by  a  temperature  of  105°,  pulse  150,  respiration  40.  At  9  A.  M., 
December  8th,  a  second  chill ;  temperature  rose  to  104°,  pulse  130 ;  three  grs. 
quinine,  and  stimulants  administered  every  two  hours. 

December  9th  and  10th,  chills,  followed  by  profuse  sweating.  December 
11th  to  15th  no  chills,  but  slight  sweating.  Temperature  from  101°  to  102°. 
Condition  otherwise  the  same  ;  pain  in  epigastrium  as  before  and  over  region 
of  liver.  December  1 5th  and  16th,  severe  chills  followed  by  sweating  in  after- 
noon ;  patient  very  restless,  and  had  had  no  sleep  for  three  or  four  nights. 
On  examination,  cedema  and  dilated  veins  over  region  of  liver  were  noticed  ; 
pain  in  right  iliac  fossa  upon  deep  pressure  ;  pain  over  stomach  the  same. 
December  17th,  Dr.  J.  B.  Deaver  in  consultation.  December  18th,  patient 
was  removed  to  the  German  Hospital. 

Post-Mortem. — Thorax. — No  effusion.  Adhesions  over  right  and  left 
apices  and  left  base. 

Lungs. — An  old  tubercular  lesion  in  left  apex  about  the  size  of  a  walnut 
healed  by  fibroid  calcareous  changes.  Congestion  and  cedema  in  remaining 
portions. 

Heart. — Cloudy  swelling  of  myo-cardium  ;  no  valvular  lesions. 

lAoer. — G-all  ducts  patulous.  In  removing  liver  and  cutting  through  the 
suspensory  ligament,  there  was  a  gush  of  purulent  fluid  apparently  sub- 
diaphragmatic. On  further  investigation  there  was  found  an  opening  in  the 
upper  back  part  of  the  right  lobe.  An  abscess  was  discovered,  about  the  size 
of  an  apple,  occupying  the  right  lobe  and  lobus  quadratus. 

Pancreas.  — Normal. 

Kidneys. — Cloudy  swelling  of  parenchyma  and  cortex. 

Appendiv. — Appendix  lay  post-caecal  and  post-colic,  was  perforated  and 
surrounded  by  pus,  which  was  in  communication  with  the  collection  found  be 
hind  the  liver. 


ACUTE  APPENDICITIS. 

M.  S. ,  female,  twelve  years  of  age,  was  admitted  to  the  Grerman  Hospital 
January  22,  1 896.  She  had  been  ill  six  days  with  severe  abdominal  pains.  The 
child  was  constipated ;  the  attending  physician  ordered  an  enema  ;  owing  to 
continued  pain,  castor  oil,  and,  later,  salines  were  prescribed.  The  patient's 
condition  not  improving,  the  physician  advised  removal  to  the  hospital  for 
operation. 

The  appendix,  post-caecal,  was  bound  down  by  adhesions.  It  was  nearly  per- 
forated at  various  points  and  contained  a  small  quantity  of  pus.  The  tissues 
were  covered  with  a  large  quantity  of  lymph.  There  was  no  pus  in  the  pelvis. 
Gauze  packing  was  used. 

Recovery  followed. 


62 


Plate  XI I 


.Adhiesioqs 


-..Plastic  lymph 


Front  view 


Threatened 
perforation 


-Garigrerious  spots 


""""--Plastic  lymph 


Back  view 


PATHOLOGY.  63 

Jn  another  case  the  pus  had  burrowed  along  the  iliac 
vessels,  and  had  presented  on  the  anterior  surface  of  the 
thigh,  near  the  knee.  If  the  appendix  holds  a  southerly 
position  we  shall  find  the  pus  in  the  pelvis. 

The  lymph-spaces  found  in  the  lymphoid  tissue  and  the 
lymphatic  vessels  of  the  appendix  and  the  meso-appendix 
may  become  occluded  by  the  exudate,  or,  together  with  the 
veins,  they  may  become  the  channels  through  which  septic 
infection  takes  place.  Lymphangitis,  from  infection,  may 
extend  to  the  lymph-channels  of  the  colon  and  mesentery 
and  thus  set  up  widespread  inflammation.  Following  this 
condition  we  often  find  a  general  non-purulent  peritonitis:  the 
inflammation  becoming  purulent  through  invasion  from  the 
intestine  brought  about  by  the  increased  virulence  of  the 
micro-organisms. 

The  veins  of  the  appendix  are  often  the  seat  of  thrombi,  the 
result  of  infection,  and  in  these  cases  we  may  find  an  exten- 
sive thrombo-phlebitis,  pyle-phlebitis,  portal  embolism,  and 
abscess  of  the  liver.  The  last  may  be  found  in  any  stage  of  the 
disease,  and  often  occurs  in  cases  that  are  apparently  too  mild 
to  attract  attention  to  the  original  seat  of  the  trouble. 

The  arterial  supply  of  the  appendix  is  often  so  interfered 
with  that  it  gives  rise  to  striking  and  interesting  phenomena. 
The  appendicular  artery  is  the  seat  of  a  proliferating  endarte- 
ritis, round  sloughs  forming  at  the  openings  of  the  arterial 
twigs,  causing  obliteration  of  their  calibre.  This  brings  about 
a  gangrenous  condition  of  the  part  supplied  by  the  particular 
twigs  affected.  At  times  on  account  of  a  deficient  blood  supply 
the  whole  appendix  sloughs.  When  the  endarteritis  does  not 
cause  total  occlusion  of  the  vessel,  we  find  a  slow  ulcerative 
process  in  the  parts  supplied  by  the  affected  branches.  The 
endarteritis  present  is  caused  by  septic  infection,  the  intima  as 
a  result  undergoing  rapid  proliferation  (Morris). 


64  APPENDICITIS. 

The  infection  may  travel  along  the  sub-peritoneal  connective 
tissue  and  cause  phlebitis  of  the  veins  of  the  lower  extremity. 
Through  this  method  of  infection,  we  may  find  encysted  extra- 
peritoneal foci  of  suppuration,  the  limiting  walls  being  formed 
by  adhesions  due  to  infection. 

The  nerves  of  the  appendix  are  affected  by  an  acute  inflam- 
mation during  the  progress  of  the  disease,  and  the  result  of  this 
nerve-complication  may  be  found  long  after  the  symptoms  of 
the  attack  have  subsided.  In  the  cicatricial  condition  following 
apparent  recovery,  we  may  have  the  nerve-fibres  so  pressed 
upon  by  the  contracting  tissues  that  they  will  be  the  cause  of 
constant  discomfort.  Another  cause  of  this  condition  may  be 
the  sclerosed  condition  of  the  nerves  themselves,  the  interstitial 
connective  tissue  undergoing  marked  hypertrophy.  I  can 
recall  cases  in  which  the  appendix  had  almost  entirely  disap- 
peared, the  remnant  being  but  a  fibrous  cord,  and  yet  the 
patient  presented  the  marked  pain  and  tenderness  of  chronic 
inflammation.  The  invalidism  present  was  no  doubt  caused 
by  this  sclerosed  condition  of  the  nerves.  The  following  case 
will  illustrate  this  condition : — 

On  October  17,  1893,  I.  E.  T.,  age  fourteen,  was  taken  with  severe  cramps 
in  his  abdomen.  Similar  attacks,  but  not  nearly  so  severe,  were  always  relieved 
by  teaspoonful  doses  of  paregoric.  The  attacks  had  always  been  produced  by 
indiscretion  in  diet. 

When  seen  the  morning  of  the  18th  he  was  suffering  very  much  and  com- 
plained of  severe  pain  all  over  the  abdomen,  which  was  associated  with 
general  abdominal  tenderness  and  decided  rigidity  of  the  abdominal  walls,  but 
more  severe  in  the  right  iliac  region.  His  stomach  was  irritable  ;  he  vomited 
dark-greenish  fluid.  Temperature  102°,  pulse  120.  Diagnosis,  acute  appen- 
dicitis with  general  peritonitis. 

Minute  doses  of  calomel  were  given  which  allayed  the  irritability  of  the 
stomach  ;  this  was  followed  by  small  doses  of  saline,  when  he  was  purged  freely. 
Turpentine  stupes  and  flaxseed  poultice  locally.  He  gradually  improved  from 
day  to  day,  and  in  two  weeks  was  convalescing.  After  the  severe  attack  he 
always  complained  of  soreness  and  discomfort  in  the  region  of  the  appendix. 
Palpation  over  this  region  never  failed  to  elicit  tenderness,  though  the  ap- 
pendix could  not  be  made  out. 


CHRONIC  APPENDICITIS. 

In  the  following  case  the  patient  was  the  wife  of  a  physician,  and  he  has 
kindly  furnished  me  with  a  detailed  history  and  analysis  of  the  treatment. 

]Mrs.  H.  early  in  April,  1895,  had  several  attacks  of  abdominal  pain  accom- 
panied by  diarrhoea.  (These  attacks  were  not  considered  of  any  importance.) 
On  April  28th,  another  severe  attack  came  on  suddenly  at  2  A.M.  At  10  A.M. 
she  had  excruciating  pain,  which,  though  general  throughout  her  bowels,  was 
particularly  severe  in  the  region  of  the  navel  and  right  iliac  fossa.  The  pain 
finally  became  localized  in  the  right  side,  and  was  accompanied  by  extreme 
tenderness,  nausea,  vomiting,  and  diarrhoea.  Her  physician  gave  her  a 
hypodermic  of  morphia ;  had  hot  poultices  applied  and  ordered  small  and 
repeated  doses  of  calomel.  The  abdomen  soon  became  distended  ;  the  pain 
and  tenderness  increased,  and  on  palpation  thickening  and  induration  were 
detected.  Appendicitis  was  diagnosed.  Consultation  was  held  as  to  the 
advisabihty  of  operation,  but  was  not  concurred  in,  as  the  consultant  held  that 
it  was  not  a  case  of  appendicitis,  but  ordinary  catarrh  of  the  bowels. 

Discontinued  the  morphia  and  continued  the  poultices ;  and  also  ^^  grain 
doses  of  calomel,  on  account  of  the  constipation  which  had  followed  the  original 
diarrhoea.  For  the  first  week,  there  was  little  change  in  her  symptoms,  calomel 
kept  the  secretion  in  a  liquid  condition.  After  the  first  week  she  showed  signs 
of  improvement,  but  upon  the  slightest  touch  she  complained  of  soreness,  and 
the  induration  remained.  Four  weeks  from  the  time  of  the  last  attack  her 
condition  was  fair,  and  upon  other  advice  operation  was  decided  upon. 

Operation  :  Parietal  peritoneum  not  adherent.  Mass  of  omentum  covering 
and  adherent  to  caecum,  which  was  deeply  congested  and  infiltrated,  resembling 
in  appearance  a  cock's  comb.  Adherent  omentum  freed,  tied  ofi",  and  cut  away. 
Caecum  exposed  with  small  collection  of  foul  pus  post-caecal.  Appendix 
adherent  to  caecum.  Appendix  liberated  and  tied  ofi"  and  removed,  when  per- 
foration was  seen  both  in  caecum  and  appendix,  allowing  the  appendix  to  empty 
its  contents  into  the  caecum.  Margins  of  perforation  in  the  caecum  freshened 
and  the  opening  closed.  Gauze  drainage.  Wound  closed  up  to  point  of  exit 
of  drain  with  interrupted  worm-gut  sutures. 

Recovery,  though  somewhat  tedious,  owing  to  a  stitch  abscess,  was  com- 
plete. 


66 


Plate  XIV 


Appendix  adherer[t  to  caecunri 


Appendix  dissected  off  sl^owiqg  perforation   into  caecum 


Perforation  upoq  detaclied  surface  of  appendix 


ACUTE  APPENDICITIS. 

M.  T.,  age  twenty-one  years,  a  theological  student,  was  admitted  to  the 
German  Hospital  December  11,  1895.  The  first  attack  occurred  one  year 
before  admission,  characterized  by  severe  pain  in  the  right  iliac  fossa  and 
vomiting.  He  was  confined  to  his  bed  for  five  days.  In  June,  1895,  he  had 
another  slight  attack.  One  week  before  admission  he  was  seized  with  violent, 
cramp-like  pains  and  severe  vomiting,  with  temperature  102°.  Examination 
showed  marked  tenderness  in  the  right  side,  rigidity,  and  swelling. 

The  operation,  performed  December  12,  1895,  revealed  an  appendiceal 
abscess  with  considerable  foul-smeUing  pus.  The  appendix  pointed  S.  E., 
was  imbedded  in  the  abscess  wall,  and  perforated  near  the  middle.  It  was 
long,  much  thickened,  and  covered  with  plastic  lymph  ;  it  was  about  the  size 
of  an  adult  finger  and  very  friable.  Faecal  concretions  were  found  in  the 
abscess  cavity.     Gauze  drainage  was  used. 

Patient  made  a  good  recovery. 


G8 


PATHOLOGY.  69 

Operation  the  following  May  showed  an  obliterated  appendix,  with  two 
small  adhesions. 

Recovery  uninterrupted,  with  complete  cessation  of  previous  symptoms. 

The  interference  with  the  abdominal  sympathetic  accounts 
for  the  neurasthenic  condition  which  in  some  cases  precedes  or 
follows  operation. 

Any  of  these  complications  mentioned  above, — thrombo- 
phlebitis, pyle-phlebitis,  portal  embolism,  abscess  of  the  liver, 
infective  peritonitis,  neuritis,  lymphangitis, — prove  that  at  any 
period  there  may  be  invasion  through  the  lymph-spaces. 
Any  of  the  stages  may  develop  independently  of  the  others, 
and  in  the  course  of  the  disease  we  may  find  the  changes  of 
one  stage  with  little,  if  any,  evidence  of  the  other.  This  is 
accounted  for  by  the  various  channels  of  infection. 

Summary. 

Four  stages  in  pathology,  but  no  distinct  line  of  demarcation 
between  them : — 

1.  Endo-appendicitis. 

2.  Parietal-appendicitis. 

3.  Peri-appendicitis. 

4.  Para-appendicitis. 

The  primary  condition  is  catarrhal  inflammation  followed 
by  microbic  invasion.     Outcome  of  attack  depends  upon : — 

1.  Drainage. 

2.  Character  and  virulence  of  micro-organisms. 

3.  Presence  or  absence  of  faecal  concretions  or  foreign 
bodies. 

Cicatricial  tissue  prominent  following  catarrhal  inflamma- 
tion, but  complete  obliteration  by  it  rare. 

Ulceration  of  appendix  walls  frequent,  and  caused  by  inter- 
stitial exudate  or  pressure  necrosis. 

Gangrene  due  to : — 

1.  Interference  with  circulation. 

2.  Twisting  of  appendix. 

3.  Embolism  of  solitary  artery  or  branch. 


70  APPENDICITIS. 

Paresis  of  appendix  common  and  due  to  inflammatory^  infil- 
tration of  muscular  wall. 

Adhesions  between  appendix  and  adjacent  serous  surfaces 
limit  pus  collections. 

In  some  acute  cases  there  is  not  time  enough  for  adhesions 
to  form  and  pus  is  found  free  in  the  general  peritoneal  cavity. 

Local  and  general  infection,  with  suppurative  foci  in  distant 
parts,  as  liver,  takes  place  by  means  of  lymphatic  and  venous 
channels.  Nerve  filaments  of  appendix  are  irritated  by  inflam- 
matory exudate  and  cicatricial  contraction  and  give  rise  to 
reflex  pain. 

Bacteriology. 

Although  the  micro-organisms  of  appendicitis  belong  to  a 
consideration  of  the  aetiology  of  the  disease,  I  prefer  to  describe 
them  in  connection  with  the  pathologic  changes  they  induce, 
as  the  part  they  play  in  the  disease  can  be  thus  more  readily 
understood. 

Investigators  have  found  about  fifteen  varieties  of  micro- 
organisms in  the  normal  intestine  of  man,  although  only  four 
of  them  are  clinically  prominent,  viz. :  the  bacillus  coli  com- 
munis;  the  staphylococcus  pyogenes  aureus;  the  streptococ- 
cus pyogenes ;  and  the  proteus  vulgaris.  The  micro-organisms 
line  the  intestine,  being  separated  from  the  absorptive  lym- 
phoid tissue  by  a  thin  basement  membrane. 

The  same  condition  is  found  in  the  normal  appendix.  In 
all  investigations,  the  bacillus  coli  communis  has  been  the  one 
most  frequently  found,  pure  cultures  of  it  having  been  made 
not  only  from  the  normal,  but  from  the  diseased  intestine  and 
appendix. 

On  account  of  its  lessened  vitality  and  its  anatomic  peculi- 
arities, invasion  of  the  appendix  occurs  more  frequently 
than  that  of  any  other  part  of  the  intestinal  tract.  The 
appendix  is  a  useless  organ,  undergoing  retrograde  metamor- 
phosis, its  powers  of  resistance  being,  necessarily,  decreased. 


Plate  XV 


Perforation 


Pus  cavitL]  -•-■ 


PATHOLOGY.  71 

The  intestine,  on  the  other  hand,  is  always  active,  and  if 
it  is  in  a  fairly  normal  condition,  can  resist  almost  any  direct 
invasion.  The  appendix,  moreover,  is  a  dependent  pouch, 
with  a  common  entrance  of  ingress  and  egress,  and  is  thus  a 
favorable  nidus  for  the  collection  and  multiplication  of  germs, 
whether  pathogenic  or  non-pathogenic.  Anything  that  inter- 
feres with  the  drainage  of  the  organ,  either  by  obstructing  the 
lumen  or  impairing  the  force  of  its  peristaltic  contractions, 
adds  to  the  probability  of  infection. 

The  most  important  determining  cause  of  an  invasion  by  the 
micro-organisms  is  the  existing  virulence  of  the  colon  bacilli. 
The  variability  of  the  virulence  of  the  bacillus  coli  communis 
is  probably  greater  than  that  of  any  other  known  micro-organ- 
ism. Why  this  is  so,  what  it  is  that  causes  this  change  in  the 
virulence  of  the  germ,  is  not  understood,  but  that  it  is  so  is 
clearly  demonstrated  in  the  pure  test-tube  cultures,  the  growth 
in  some  being  much  more  active  than  in  others ;  while  inocu- 
lations from  the  different  tubes  show  decided  differences  in 
degree  of  virulence.  If  the  colon  bacillus  is  non-virulent  the 
appendix  may  possess  the  resistant  power  required  to  over- 
come its  action ;  but  if  this  bacillus  is  virulent,  the  resistant 
strength  of  the  appendix  will  be  of  little  account.  Hodenpyl, 
in  an  investigation  of  61  cases  of  peritoneal  inflammation 
consequent  upon  appendicitis,  obtained  the  colon  bacillus  in 
57  cultures,  and  in  50  of  these  it  was  unassociated  with  any 
other  germ.  In  cases  of  mixed  infection,  we  generally  find 
the  staphylococcus  or  the  streptococcus  associated  with  the 
colon  bacillus,  the  latter  combination  being  much  more 
intense  in  its  action. 

The  character  of  the  attack  depends,  to  a  great  extent,  upon 
this  infection ;  upon  the  power  of  resistance  possessed  by  the 
organ  at  th'e  time  of  the  invasion ;  upon  the  condition  of  the 
lymphatics  and  blood-vessels ;  and  upon  the  condition  of  the 


72  APPENDICITIS. 

muscular  coats  of  the  organ.  We  may,  however,  have  just  as 
severe  cases  in  which  the  bacillus  coli  communis  is  the  only 
factor  in  the  causation.  If  the  lymphatics,  blood-vessels,  and 
muscular  fibres  are  in  a  healthy  and  active  condition,  there  is 
less  liability  of  a  severe  attack,  as  the  appendix  will  be  enabled, 
at  least  to  some  extent,  to  check  the  disease.  If  the  opposite 
conditions  prevail,  the  micro-organism  will  have  full  play,  and 
the  severity  of  the  attack  will  be  correspondingly  increased. 
Thus,  if  we  have  the  debris  of  mucus,  and  fsecal  matter  re- 
tained within  the  appendix,  or  if  fsecal  concretions  are  present, 
there  will  necessarily  be  a  greater  degree  of  inflammation  and 
a  more  rapid  course  of  the  disease. 

As  before  mentioned,  the  outcome  of  the  micro-organismal 
invasion  will  be  modified  by  the  freedom  of  drainage  to  a 
greater  extent  than  by  any  other  factor.  At  times  the  layer 
of  cellular  tissue  that  replaces  the  mucous  membrane  is  so 
dense  that  it  resists  the  invasion  of  micro-organisms,  but 
dilates  under  the  increased  pressure  caused  by  the  contained 
action  of  the  germs,  and  in  such  cases  we  find  the  hour- 
glass-shaped bulging  of  the  walls  of  the  appendix,  or,  if  the 
obstruction  be  at  the  entrance  to  the  canal,  the  ballooning  of 
the  whole  length  of  the  organ. 

The  micro-organisms  of  typhoid  fever,  of  tuberculosis,  and  of 
actinomycosis  have  been  found  in  the  appendix,  but  their 
presence  in  this  locality  is  rare. 


SYMPTOMS. 

In  considering  the  symptoms  of  appendicitis,  it  must  be 
borne  in  mind  that  it  is  not  always  possible  to  determine  the 
pathologic  change  by  the  apparent  symptoms.  Any  attempt 
to  describe  symptoms  which  positively  indicate  the  progress 
of  the  disease  would  be  futile.  While  it  is  true  that  the 
symptoms  become  more  marked  when  perforation,  pus  forma- 
tion, or  gangrene  supervene,  it  is  also  a  fact  that  remission 
of  all  the  symptoms,  except  local  tenderness,  may  occur,  and 
yet  the  disease  may  be  progressing  steadily  to  a  fatal  termina- 
tion. 

I  shall  speak  of  two  forms  of  appendicitis,  the  acute  and 
the  chronic. 

The  acute  form  embraces  those  varieties  described  as  ulcera- 
tive, perforative,  and  gangrenous.  These  terms  represent 
only  the  differences  in  the  degree  of  local  inflammation, 
between  which  it  is  clinically  impossible  to  draw  a  line  of 
distinction.  It,  therefore,  appears  more  practical  to  describe 
them  under  one  collective  heading.  The  same  is  true  of 
chronic  appendicitis,  under  which  heading  are  included  the 
varieties  described  as  subacute,  relapsing,  and  recurrent. 

There  are  three  symptoms  of  appendicitis  so  constant,  and, 
when  associated,  so  characteristic  of  the  affection,  that  I  style 
them  the  "  Three  Cardinal  Symptoms ; "  these  are  pain, 
tenderness,  and  rigidity,  each  of  which  I  will  describe  in 
detail. 

Pain  is  the  initial  symptom,  and  usually  follows  the 
ingestion  of  foods,  either  indigestible,  improperly  masticated, 
or  hastily  swallowed.     At  the  onset,  the  character  of  the  pain 

73 


74  APPENDICITIS. 

is  paroxysmal  and  colicky,  to  this  extent  simulating  an 
attack  of  acute  indigestion  or  bilious  colic.  The  term  appen- 
dicular colic  has  been  applied  to  this  initial  pain,  but  to  this 
name  objection  has  been  raised,  since  the  cause  of  pain  is 
inflammatory  and  not  functional.  While  acknowledging  such 
to  be  the  case,  I  am,  nevertheless,  convinced  that  the  pain  may 
be  paroxysmal  because  otherwise  it  is  difficult  to  explain 
the  wave-like  exacerbations,  so  vividly  described  by  intelligent 
patients. 

Palpation  over  the  affected  area,  motion  involving  the 
action  of  the  right  psoas  muscle,  bending  the  body  to  the 
left,  deep  inspirations,  or  coughing, — all  these  excite  and 
intensify  the  peculiar,  undulating,  characteristic  pain.  As 
the  pain  is  partly  due  to  appendiceal  inflammation,  its  general 
colicky  character  is  probably  the  result  of  irritation,  reflected 
along  the  numerous  branches  of  the  superior  mesenteric 
plexus  of  the  sympathetic,  one  of  which  supplies  the  appendix. 
This  irritation  is  held  to  be  the  result  of  the  presence  of  fsecal 
concretions  or  foreign  bodies.  I  cannot  think  that  the 
mere  presence  of  these  substances  will  account  for  the  irrita- 
tion, as  we  are  compelled  to  acknowledge  the  fact  that  such 
are  found  in  many  normal  appendices.  And  again,  we  have 
attacks  of  this  colic  due  co  disease  of  the  appendix,  in  which 
the  lumen  is  entirely  free  from  all  concretions.  In  its  efforts 
to  expel  material  from  its  canal,  the  peristalsis  of  the  appendix 
has  been  given  as  a  definite  cause  of  this  irritation,  but  I 
cannot  entirely  agree  with  this  view,  because  of  the  fact  that, 
without  any  such  symptoms,  the  normal  appendix  empties 
itself  during  health.  I  believe,  however,  that  the  paroxysms 
of  colic  are  largely  due  to  the  erratic  peristalsis  of  the  inflamed 
appendix,  induced  by  the  effort  to  rid  itself  of  foreign  material. 
Fowler  has  taken  exception  to  the  term  appendicular  colic, 
offering  as  an  argument  against  it  the  fact  of  the  imperfect 


SYMPTOMS.  75 

development  of  the  circular  muscular  fibres  of  the  appendix, 
whence  its  inability  by  expulsive  efforts  to  cause  colicky  pain. 
I  cannot  agree  with  this  view,  and  particularly  as  regards  the 
absence  of  circular  muscular  fibres,  as  this  organ  possesses  a 
continuous  circular  muscular  coat.  I  grant  fthat  the  circular 
muscular  fibres  are  not  always  so  well  developed  as  the 
longitudinal  ones,  but  I  am  convinced  that  the  appendix 
usually  possesses  sufficient  contractile  power  to  cause  colicky 
pain  by  muscular  contraction.  The  study  of  pathologic 
appendices  cannot  be  relied  upon  to  demonstrate  normal 
histologic  facts.  The  dissection  of  normal  appendices  proves 
the  presence  of  circular  muscular  fibres.  The  irritation, 
arising  from  simple  catarrhal  inflammation  of  an  appendix, 
in  which  there  is  no  faecal  concretion  or  foreign  body,  is 
capable  of  inducing  expulsive  efforts  that  cause  colicky  pain, 
just  as  in  an  inflamed  rectum  or  bladder.  Under  such  cir- 
cumstances, the  presence  of  a  foreign  body  serves  merely  to 
intensify  the  pain. 

The  Location  of  Pain. — As  described  by  the  patient,  the 
primary  pain  is  most  frequently  referred  to  the  umbilicus  or 
peri-umbilical  region ;  next  in  order  of  frequency  to  the  epi- 
gastrium ;  and  last  of  all  to  the  region  of  the  appendix.  In 
fact,  the  pain  of  appendicitis  may  be  referred  to  any  portion  of 
the  abdomen.  And  this  it  is  that  has  led  to  so  many  mistakes 
in  diagnosis.  After  the  occurrence  of  localized  peritonitis  in 
the  right  iliac  fossa  the  pain  is  there  located.  Not  infrequently 
it  is  referred  to  the  left  side  of  the  abdomen. 

The  location  of  the  secondary  pain  to  a  large  extent  depends 
upon  the  position  of  the  appendix.  If  the  appendix  is  long, 
with  its  tip  overhanging  the  brim  of  the  pelvis,  the  pain  will 
be  referred  to  the  left  side  of  the  abdomen,  along  the  course 
of  the  spermatic  cord  toward  the  testicle,  or  to  the  pelvis.  If 
the  appendix  is  post-csecal  and  pointing  north,  the  pain  may  be 


76  APPENDICITIS. 

referred  to  the  loin  or  back  ;  at  times,  if  the  appendix  points 
north,  lying  either  in  front  or  back  of  the  caecum,  the  pain 
may  be  referred  to  the  kidney  or  to  the  liver.  As  a  rule, 
the  pain  will  be  more  marked  in  the  right  iliac  fossa.  If, 
however,  the  tip  of  the  appendix  occupies  the  left  iliac  fossa 
the  greatest  amount  of  pain  will  be  referred  to  that  region.  In 
a  certain  class  of  chronic  cases  the  pain  which  is  increased  on 
motion  may  be  referred  to  the  leg  along  the  course  of  the 
anterior  crural  nerve  or  even  to  the  knee.  This  occurs  when 
the  appendix  occupies  the  pelvis. 

The  Character  of  the  Pain. — Too  much  stress  cannot  be  laid 
upon  the  paroxysmal  nature  of  the  initial  pain.  In  fact,  I 
have  seen  numerous  cases  in  which  this  has  been  attributed  to 
biliary  or  nephritic  colic,  being  quite  as  severe  as  in  those 
affections. 

Tenderness  upon  pressure  is  one  of  the  most  valuable  and  con- 
stant of  all  the  signs  of  appendicitis.  It  is  always  present.  If 
the  appendix  is  post-csecal  and  the  rigidity  of  the  abdominal 
walls  marked,  the  tenderness  is  more  difficult  to  elicit,  and 
requires  deep  palpation.  It  is  sometimes  best  elicited  through 
the  rectum  or  vagina.  In  women  the  possibility  of  a  right- 
sided  pyo-salpinx  or  salpingitis  must  also  be  borne  in  mind. 
In  rare  cases  the  tender  spot  ma}'^  be  located  in  the  loin,  and 
discovered  only  by  deep  palpation.  After  the  advent  of  sup- 
puration with  the  increased  amount  of  pus  the  tenderness  in 
the  right  iliac  fossa  becomes  more  general.  Frequently  after 
the  remission  following  the  sudden,  sharp  primary  attack, 
tenderness  and  rigidity  alone  remain  to  tell  the  attending 
physician  that  trouble  still  exists.  The  point  of  greatest  in- 
tensity is  usually  over  the  inflamed  appendix,  but  to  this  rule 
there  are  exceptions.  Recently  in  a  young  adult  male  I  found 
the  point  of  greatest  tenderness  to  the  left  of  the  left  rectus 
muscle,  a  little  above  the  level  of  the  anterior  superior  spine 


SYMPTOMS.  77 

of  the  ilium.  By  rectal  examination  a  small  but  very  sensi- 
tive mass  was  detected  occupying  the  recto-vesical  space. 
Operation  demonstrated  the  appendix  occupying  this  position. 
The  point  of  greatest  intensity,  however,  usually  corresponds 
to  the  so-called  McBurney's  point,  which  is  located  midway 
between  the  umbilicus  and  the  right  anterior  superior  iliac 
spine, 

I  recall  two  cases  in  which  the  point  of  greatest  tenderness 
was  immediately  above  the  middle  of  Poupart's  ligament. 
This,  as  demonstrated  by  operation,  corresponded  to  the  angle 
of  curve  in  the  appendix ;  in  both  cases  the  origin  was  from 
the  postero-external  aspect  of  the  base  of  the  caecum,  descend- 
ing in  front  of  the  latter  as  far  as  the  apex,  where  it  abruptly 
curved  upward. 

Rigidity  of  the  Abdominal  Walls. — Next  to  pain  this  is  one  of 
the  most  reliable  signs.  It  is  usually  confined  to  the  right  side 
of  the  abdomen,  is  most  marked  over  the  inflamed  region,  and 
immediately  follows  the  localization  of  pain  in  this  locality. 
In  some  instances  the  rigidity  is  so  pronounced  that  it  pre- 
vents deep  palpation,  and  in  addition  makes  the  percussion- 
note  of  higher  pitch.  When  the  pain  has  been  referred  to  the 
left  side  and  suppuration  has  supervened,  the  pus  collection 
occupying  the  pelvis,  there  will  be  marked  bilateral  rigidity  of 
the  recti  muscles  and  of  the  lower  abdominal  wall. 

Although  the  "  three  cardinal  symptoms  "  are  the  most  im- 
portant indications  of  appendicitis,  there  are  others  presenting 
themselves  with  more  or  less  regularity.  Among  these  should 
be  noticed  disturbances  of  the  gastro-intestinal  tract,  elevation 
of  temperature,  increase  of  the  pulse-rate  and  of  the  respiration, 
abnormality  of  the  urine,  etc. 

Vomiting. — Coincident  with  the  onset  of  the  initial  pain 
there  may  be  vomiting.  In  favorable  cases  this  usually  does 
not  persist,  and  subsides  with  the  localization  of  pain  in  the 


78  APPENDICITIS. 

right  iliac  fossa ;  in  unfavorable  cases  it  is  continuous  and  un- 
controllable. The  ejecta  consist  first  of  the  gastric  contents, 
later  of  bile,  and  lastly,  if  intestinal  paresis  has  followed  a 
septic  peritonitis,  of  stercoraceous  matter.  When  the  vomitus 
becomes  stercoraceous,  it  is  thrown  off  by  regurgitation,  and 
indicates  a  fatal  termination.  Nausea  and  vomiting  may 
sometimes  be  absent. 

Constipation. — In  the  majority  of  cases  of  appendicitis  con- 
stipation is  present,  but  diarrhoea  sometimes  ushers  in  the 
attack,  particularly  in  those  cases  which  from  the  onset  bear 
an  unfavorable  appearance.  Obstinate  constipation  early  in 
the  disease  is  due  either  to  intestinal  paresis,  the  result  of 
infection,  or  to  the  indiscriminate  use  of  opium.  Although 
these  conditions  seem  to  play  but  little  or  no  part  in  the 
causation  of  an  attack,  the  bowels  being  previously  in  a 
normal  condition,  yet,  as  soon  as  infection  takes  place,  there 
is  almost  always  a  decided  change.  This  constipation,  with 
vomiting,  has  in  the  early  stage  of  the  disease  led  to  many 
errors  in  diagnosis,  the  affection  of  the  appendix  having  been 
mistaken  for  acute  strangulation  or  some  other  form  of  intes- 
tinal obstruction.  The  constipation  is  probably  due  to  reflex 
paralysis  of  the  large  bowel. 

The  temperature  and  the  pulse-rate  bear  no  direct  relation  to 
the  gravity  of  the  attack.  At  the  onset  there  is  usually  an 
elevation  of  temperature  varying  from  100°  to  102°  or  103°  F. 
We  may  have  early  perforation  and  gangrene  of  the  appendix 
with  but  a  moderate  rise  of  temperature ;  on  the  other  hand, 
there  may  be  a  decided  rise  with  a  simple  catarrhal  inflamma- 
tion. The  pulse  in  the  former  class,  i.  e.,  those  with  early  per- 
foration and  gangrene,  more  nearly  corresponds  to  the  gravity 
of  the  attack.  A  sudden  fall  of  temperature  to  the  normal  or 
subnormal  by  no  means  warrants  a  favorable  outlook,  as  it  too 
often  indicates  the  lull  immediately  preceding  the  storm  of 


SYMPTOMS.  79 

destruction,  perforation,  or  a  ruptured  abscess.  The  thermom- 
eter is,  therefore,  a  most  unreliable  instrument  as  an  indicator 
of  the  gravity  of  an  attack. 

Restlessness. — Marked  restlessness  occurring  in  the  course  of 
an  attack,  especially  in  children,  denotes  the  presence  of  pus. 

Tumescence. — In  a  few  cases  there  will  be  a  bulging  of  the 
right  iliac  region  not  due  to  distention  of  the  bowel.  This  is 
not  frequently  observed  unless  an  abscess  is  present. 

Abdominal  distention  may  be  due  to  several  causes:  to 
mechanical  obstruction  by  bands  of  adhesions;  to  paralysis 
of  the  intestine ;  to  septic  causes ;  to  obstinate  constipation 
with  resultant  collection  of  gas.  Richardson  points  out  the 
possible  differential  diagnosis,  by  means  of  auscultation, 
between  distention  due  to  accumulated  gas  and  that  due 
to  paralysis  of  the  intestine  the  result  of  infection,  the  sounds 
of  peristaltic  action  being  clearly  heard  in  the  former  condi- 
tion but  not  in  the  latter.  The  distention  may  sometimes  be 
limited  to  the  right  side  of  the  abdomen ;  in  this  condition 
only  that  portion  of  the  gut  contiguous  with  the  inflamed 
area  is  affected.  This  local  distention  may  be  marked,  because 
the  still  functionally  active  intestine  will  force  more  gas  into 
the  affected  portion.  If  peritonitis  becomes  diffused,  the 
abdomen,  though  generally  distended,  is  sometimes  flat  with 
its  walls  rigid  and  hard,  a  condition  appearing  early  and 
arising  from  the  complete  paralysis  of  the  intestinal  canal, 
which  prevents  the  entrance  of  gas.  A  distended  abdomen, 
or  one  in  which  the  distention  is  particularly  marked  over  the 
epigastrium,  either  condition  being  associated  with  persistent 
and  uncontrollable  vomiting,  is  a  combination  pointing  to  an 
unfavorable  termination. 

The  tongue  is  furred,  and  if  diffuse  peritonitis  occurs,  may 
become  dry;  and  associated  with  a  deposit  of  sordes  upon  the 
teeth.     In  severe  types  the  tongue  is  fissured. 


80  APPENDICITIS. 

The  Urine  and  the  Bladder. — The  urine  is  usually  diminished 
in  amount,  and  often  contains  albumin  and  indican.     Several 
theories  have  been  advanced  to  explain  this  diminution  in 
quantity  and  presence  of  albumin  in  the  urine.     The  most 
tenable  of  these   is   that   there   is   decreased   activity   of  the 
glomerules  of  the  kidney,  due  to  the  general  fall  in  arterial 
tension.     From  the   first,  frequency  of  urination   is   often  a 
prominent  symptom  and  is  probably  due  to  disturbance  of  the 
sympathetic  nerves,  and,  when  an  inflamed  appendix  occupies 
the  pelvis,  to  a  directly  communicated  irritation  of  the  bladder. 
In  peritonitis  involving  the  serous  coat  of  the  bladder,  reten- 
tion of  urine  may  occur,  necessitating  the  use  of  the  catheter. 
It  is  uncertain  what  influence  inflammation  of  the  appendix 
may  have  upon  the  function  of  the  kidneys,  but  experience  has 
taught  me  that  acute  and  subacute  nephritis  is  of  frequent 
occurrence.     Whether  the  two  conditions  exist  in  the  relation 
of  cause  and  eff'ect  I  am  not  prepared  to  say.     Theoretically 
the  causal  relation  would  not  appear  to  exist,  but  as  practice 
and  theory  are  so  often  totally  diff'erent  it  must,  until  further 
demonstration,  remain  an  open  question.     I  have  records  of 
numerous  cases  in  which  there  were  present  blood,  granular, 
compound  granular,  and  hyaline  casts,  with  albumin,  and  a 
marked  diminution  in  the  amount  of  urine  secreted,  in  most 
of  which  the  urine  became  perfectly  normal  during  conva- 
lescence.    This  observation  is  purely  clinical  and,  like  many 
such,  must  stand  as  true.     It  may  be  that  the  sympathetic 
system,  as  it  is   in   other  intra-abdominal  inflammations,  is 
responsible,  although  not  to  the  same  extent  as  in  appendicitis. 
Respiration. — Respiration     plays    a     comparatively     unim- 
portant part  in  the  symptomatology  of  most  cases  of  appen- 
dicitis,  although   early   in  the   attack   there   is   a   voluntary 
limitation  in  breathing,  the  patient  favoring  costal  respiration. 
If  the  distention  is  pronounced,  the  respiration  is  correspond- 


SYMPTOMS.  81 

ingly  labored,  while  if  there  is  active  peritonitis  the  resjDiration 
is  thoracic.  In  advanced  cases  of  appendicitis  with  a  diffuse 
peritonitis,  I  have  noticed  a  peculiar  reflex  condition  of  the 
pharynx,  described  by  the  patient  as  a  difficulty  in  swallowing. 
Very  rapid  respiration  due  to  septic  absorption  becomes  a 
grave  symptom,  as  in  a  very  large  percentage  of  such  cases  it 
indicates  pulmonary  involvement. 

Leucocytosis,  according  to  Richardson,  is  an  invariable  symp- 
tom in  perforative  appendicitis.  I  cannot,  however,  consider  it 
of  any  marked  value,  as  the  condition  of  the  appendix  will 
demand  its  removal  long  before  leucocytosis  can  be  demon- 
strated. 

Palpation  of  the  Appendix. — During  an  acute  attack  there 
will,  as  a  rule,  be  such  marked  tenderness  over  the  region  of 
the  appendix  that  it  will  be  practically  impossible  to  palpate 
the  diseased  organ.  Moreover,  in  the  acute  stage  of  the 
disease,  the  rigidity  of  the  abdominal  walls  will  also  hinder 
proper  palpation.  The  method  described  by  Edebohls  is, 
therefore,  of  little  value,  although  in  the  diagnosis  of  chronic 
appendicitis  it  plays  a  most  important  part.  I  shall,  there- 
fore, describe  his  method  when  considering  the  symptoms  of 
the  latter  affection. 

Chronic  Appendicitis. — The  symptoms  of  chronic  appendi- 
citis are  more  variable  than  those  of  the  acute  affection.  The 
most  constant  of  all  is  pain,  which  is  usually  confined  to  the 
right  iliac  fossa,  is  subacute  in  character,  and  varies  with  the 
condition  of  the  general  intestinal  tract. 

If  there  is  exudate  with  adhesions,  and  especially  if  a 
portion  of  the  great  omentum  is  involved,  palpation  will 
demonstrate  more  than  if  the  appendix  alone  is  affected.  In 
chronic  appendicitis,  palpation  reveals  an  enlarged  and  in- 
flamed appendix,  with  more  or  less  tenderness,  the  severity  of 
which  depends  upon  the  presence  or  absence  of  pus.  Edebohls 
6 


82  APPENDICITIS. 

describes  his  method  of  palpating  the  appendix  in  women 
as  follows :  "  After  completion  of  the  ordinary  bimanual 
examination  of  the  pelvic  organs,  the  patient  is  drawn  upward 
upon  the  table  about  a  foot,  her  feet  still  remaining  where 
they  were  placed  for  the  vaginal  examination.  This  is  mainly 
for  the  purpose  of  unfolding  the  flexure  of  the  thigh  upon  the 
abdomen,  and  to  render  the  right  iliac  region  more  accessible 
to  the  palpating  hand.  One  hand  only,  applied  externally, 
is  required  for  the  practice  of  palpation  of  the  vermiform 
appendix.  No  assistance  can  be  rendered  by  a  finger  intro- 
duced into  the  vagina,  and  very  little  assistance,  and  that 
only  occasionally,  by  a  finger  introduced  into  the  rectum. 
Standing  at  the  patient's  right,  the  examiner  begins  the  search 
for  the  appendix  by  applying  two,  three,  or  four  fingers  of  the 
right  hand,  the  palmar  surface  downward,  almost  flatly  upon 
the  abdomen,  in  a  straight  line  from  the  umbilicus  to  the 
anterior  superior  spine  of  the  right  ilium.  He  notices  suc- 
cessively the  character  of  the  various  structures  as  they  come 
beneath  and  escape  from  the  fingers  passing  over  them.  In 
doing  this,  the  pressure  exerted  must  be  sufficiently  deep  to 
recognize  distinctly,  along  the  whole  route  traversed  by  the 
examining  fingers,  the  resistant  surfaces  of  the  posterior  ab- 
dominal wall  and  of  the  pelvic  brim.  Only  in  this  way  can 
we  positively  feel  the  normal,  or  the  but  slightly  enlarged 
appendix;  pressure  less  than  this  must  necessarily  fail." 
Not  infrequently  such  examinations  excite  an  acute  exacer- 
bation from  the  irritation  produced  by  the  manipulation. 

If  the  tenderness  and  pain  are  marked,  we  shall  usually 
find  pus  encapsulated  either  within  the  appendix  or  between 
the  layers  of  the  meso-appendix.  Associated  with  the 
presence  of  the  chronically  inflamed  appendix  there  are 
evidences  of  intestinal  indigestion,  discomfort,  of  pain  in- 
creased  by  exertion    and   referred    particularl}^  to   the  right 


SYMPTOMS.  83 

iliac  fossa,  and  mucous  diarrhoea  alternating  with  constipa- 
tion. There  is  indisposition  and  general  debility.  Neuras- 
thenia is  often  an  associated  condition.  Exercise  or  un- 
digested food,  by  increasing  peristalsis  and  thus  pulling  upon 
the  adhesions,  frequently  cause  exacerbations  of  pain.  Fever 
is  of  importance  only  when  of  the  hectic  type. 

Summary. 
No   distinct   relation    between    symptoms   and    pathologic 
change. 

Acute  Appendicitis: — 

1.  Ulcerative. 

2.  Perforative. 

3.  Gangrenous. 

"Three  cardinal  symptoms  :  " — 

1.  Pain. 

2.  Tenderness. 

3.  Rigidity. 

Pain  usually  appears  after  eating;  at  first  is  colicky  and 
referred  to  epigastrium ;  later  becomes  localized  usually  to  site 
of  appendix. 

Tenderness  is  always  present,  sometimes  best  elicited  by  rec- 
tal or  vaginal  examination. 

Point  of  greatest  tenderness  usually  over  appendix. 

Rigidity  usually  right  sided  ;  follows  localization  of  pain  and 
is  most  marked  over  inflamed  area. 

Vomiting  common  at  onset  of  attack.  Desists  in  favorable 
cases  ;  its  prolongation  is  a  serious  symptom. 

Chronic  Appendicitis. — History  important.  Palpation 
most  valuable  means  of  diagnosis. 

Localized  pain  and  tenderness  most  constant  symptoms. 


DIAGl^OSIS. 

The  diagnosis  of  appendicitis  is,  ordinaril}^,  quite  simple. 
When  the  three  cardinal  symptoms  are  present,  viz.,  sudden 
onset  of  acute  abdominal  pain,  with  or  without  vomiting, 
occurring  in  one  previously  well ;  unilateral  rigidity  of  the 
lower  abdominal  wall ;  tenderness  over  the  site  of  the  ap- 
pendix,— the  diagnosis  of  appendicitis  is  unexceptionally 
warranted.  That  the  diagnosis  is  not  always  made  ma}^  be 
variously  accounted  for,  but  chiefly  by  the  still-lingering 
picture  of  an  inflamed  caecum,  its  lumen  filled  with  faecal 
matter,  and  general  inflammation  surrounding  the  organ, — 
the  appendix  being  placed  far  in  the  background,  so  far,  in 
fact,  that  absolutely  no  significance  is  attached  to  its  condition. 
If,  from  the  mental  picture,  the  caecum  could  be  entirely 
removed,  and  in  its  place  be  put  an  inflamed  and  angry 
appendix,  mistakes  in  diagnosis  would  be  of  less  frequent 
occurrence. 

Failures  in  diagnosis  may  often  be  explained  by  the  fact 
that  the  initial  symptoms  are  lost  from  sight,  or  have  been 
entirely  concealed  by  the  injudicious  use  of  opium.  The 
ushering  in  of  an  attack  of  appendicitis  very  closely  simulates 
acute  indigestion,  with  the  same  vomiting,  colicky  j)ains, 
often  extending  over  the  entire  abdomen,  and  soreness  of  the 
abdominal  walls.  In  appendicitis,  however,  the  general  ab- 
dominal pain  soon  becomes  localized  in  the  right  iliac  fossa, 
when  we  should  at  once  suspect  the  presence  of  more  serious 
trouble  than  simple  indigestion.  The  tenderness  on  pressure 
also  becomes  localized,  the  point  of  greatest  intensity  usually 
corresponding  to   the  position  of  the  inflamed   organ.     This 

84 


DIAGNOSIS.  85 

tenderness  is  one  of  the  most  important  and  constant  signs  on 
which  to  base  a  diagnosis.  It  is  alwaj^s  present,  and  may  be 
eUcited  by  simple  pressure  of  the  tip  of  the  finger.  As  a  rule, 
there  is  a  distinct  relationship  between  the  degree  of  tender- 
ness and  the  degree  of  inflammation.  Although  the  point  of 
tenderness  generally  corresponds  to  McBurney's  point,  much 
depends  upon  the  position  of  the  appendix,  whether  it  be 
anomalous  or  otherwise.  It  is  here  that  the  value  of  a  rectal 
or  vaginal  examination  must  be  remembered. 

If  the  appendix  holds  a  southerly  direction,  and  overhangs 
the  brim  of  the  pelvis,  the  point  of  greatest  tenderness  will  be 
found  by  rectal  or  vaginal  examination,  although,  except  a 
sense  of  fulness,  nothing  else  by  such  means  will  be  demon- 
strated. In  these  cases,  one  may  err  by  the  fact  that,  when 
palpating  the  abdominal  wall,  no  especial  point  of  tenderness 
will  be  found  there ;  but  either  a  rectal  or  a  vaginal  examination, 
or  a  combination  of  the  two,  must,  nevertheless,  be  made,- 
whereby  a  point  of  marked  tenderness  will  often  be  detected. 

The  point  of  greatest  tenderness  may  be  immediately  above 
the  middle  of  Poupart's  ligament,  or  to  the  left  of  the  linea 
alba,  or  in  either  the  lumbar  or  hepatic  regions,  the  location 
depending  upon  the  position  of  the  appendix  and  the  site 
of  the  inflammation. 

In  acute  cases,  it  is  usually  not  at  all  difficult  to  elicit 
tenderness.  When  asked  where  the  greatest  intensity  of  pain 
is  located,  the  patient  himself  will,  almost  invariably,  direct 
our  attention  to  the  appendix ;  palpation  over  this  region  will 
elicit  tenderness,  while  wave-like  exacerbations  of  pain  are 
provoked.  In  chronic  cases,  it  may  be  more  difficult  to  locate 
the  tenderness,  but  deep,  firm  pressure  will  rarely  fail  to 
provoke  flinching  and  pain,  thus  demonstrating  the  presence 
of  a  diseased  organ. 

Between  the  extent  of  the  disease  and  the  degree  of  tender- 


86  APPENDICITIS. 

ness  there  is  generally  a  close  relation.  As  a  rule,  increase  of 
tenderness  denotes  a  progressive  inflammation,  while  decrease 
of  tenderness,  accomplished  without  the  administration  of 
anodynes,  usually  indicates  a  favorable  course. 

If  pus  is  present,  the  degree  of  tenderness  will  be  so  great 
that  no  difficulty  should  be  experienced  in  localizing  the  point 
of  greatest  intensity.  If,  however,  septic  absorption  has  pro- 
gressed so  far  that  paralysis  of  the  nerve-filaments  has  been 
caused,  we  may  find  that  the  tenderness  has  almost  disap- 
peared, and  this  without  a  corresponding  diminution  in  the 
progress  of  the  disease.  Under  such  circumstances,  the  other 
signs  will  be  so  marked  that  there  should  be  no  difficulty  in 
reaching  a  diagnosis. 

With  few  exceptions,  localized  tenderness  will  increase  ac- 
cording to  the  development  of  the  disease.  Thus,  the  forma- 
tion of  pus  gives  rise  to  excruciating  pain ;  over  an  appendix 
undergoing  gangrenous  change  the  tenderness  is  marked ; 
perforation,  with  the  formation  of  a  large  abscess,  causes  in- 
creased tenderness,  although  this  may  not  be  so  decided  as  in 
those  cases  wherein  a  small  abscess  is  confined  to  the  lumen 
of  the  appendix,  or  to  a  small  area  of  the  meso-appendix.  If 
the  peritoneum  becomes  generally  infected,  the  tenderness  will 
be  more  widespread,  and  may  extend  over  the  entire  surface 
of  the  abdomen ;  at  first  general,  or  more  or  less  confined  to 
the  umbilical  or  peri-umbilical  region,  the  pain,  as  the  disease 
continues,  becomes  more  localized,  generally  to  the  right  iliac 
fossa. 

The  position  of  the  pain  will  vary  with  the  position  and 
direction  of  the  appendix.  Thus,  in  cases  in  which  the 
appendix  points  north,  the  pain  may  be  referred  to  the  lumbar 
or  hepatic  regions.  In  certain  cases,  the  pain  is  referred 
entirely  to  the  left  side,  although  this  does  not,  as  a  rule, 
indicate  that  the  appendix  points  east,  as  in  these  instances  it 


DIAGNOSIS.  87 

more  generally  points  south,  and  occupies  the  pelvis.  This 
fact  should  be  emphasized,  as  I  have  seen  a  number  of  exam- 
ples in  whicli  the  attending  physicians,  who  were  familiar 
with  the  general  symptoms  of  appendicitis,  were  totally  misled. 
The  citation  of  one  case,  that  of  the  son  of  a  ffhysician,  will 
serve  to  illustrate  the  importance  of  pain  referred  to  the  left 
side  as  indicative  of  the  pelvic  position  of  the  appendix. 

Master  A. ,  shortly  after  a  meal  of  indigestible  food,  was  suddenly  seized 
with  acute  abdominal  pain,  vomiting,  and  rigidity  of  the  right  lower  abdomi- 
nal wall.  Symptoms  of  acute  peritonitis  developed  in  three  days,  at  which 
time  the  father  consulted  me,  saying  that  he  would  have  regarded  the  case  as 
one  of  appendicitis  had  not  the  pain  been  referred  to  the  left  side.  I  told 
him  that  in  my  opinion  the  disease  was  appendicitis,  and  that  operation  was 
immediately  demanded.  Two  days  later  I  was  hastily  summoned  to  see  the 
boy,  whom  I  found  suiFering  from  a  diffuse  peritonitis  of  an  active  tyi^e,  the 
pulse-rate  130,  with  a  "  leaky"  skin,  and  constant  retching  and  constipation. 
I  declined  to  interfere  except  to  advise  total  discontinuance  of  opium  or  any 
of  its  preparations,  and  ordered,  instead,  small,  repeated  doses  of  calomel  to 
the  extent  of  free  purgation.  I  believed  this  a  wiser  course  to  pursue  than  to 
operate.  Apparent  recovery  followed.  I  then  advised  operation  in  order  to 
prevent  recurrence,  but  the  father  could  not  agree  to  have  his  son  operated 
upon  when  in  apparent  good  health.  Within  ten  days  a  second  attack 
occurred  ;  I  was  again  summoned,  but  being  absent  from  home,  other  counsel 
was  sought ;  operation  was  again  deferred,  resulting  in  a  second  incomplete 
recovery.  Again  I  was  consulted,  and  as  before  I  advised  operation,  which 
this  time  was  consented  to.  The  appendix,  the  tip  of  which  contained  a  pus- 
collection,  and  the  whole  surrounded  by  an  encysted  abscess,  was  found  occupy- 
ing the  pelvis,  adherent  to  its  floor  and  to  the  right  of  the  rectum.  The 
appendix  was  removed  and  recovery  was  uneventfiil. 

In  those  cases,  therefore,  in  which  the  pain  is  referred  to 
the  left  side,  with  the  point  of  greatest  tenderness  immediately 
above  the  pubis,  or  in  the  left  iliac  fossa,  the  greatest  intensity 
of  the  inflammation  will  be  confined  to  the  tip  of  the  ap- 
pendix. It  is  in  the  class  of  cases  in  which  the  appendix 
occupies  the  pelvis  that  vesical  symptoms,  such  as  irritability, 
frequent  micturition,  and  retention,  are,  from  a  diagnostic 
standpoint,  of  value. 

The  abrupt  cessation  of  pain  previously  located  in  the  region 


88  APPENDICITIS. 

of  the  appendix,  followed  by  a  fall  of  temperature,  increased 
pulse-rate,  and  an  anxious  expression,  are  symptoms  which 
indicate  the  occurrence  of  gangrene. 

From  experience  in  operating  upon  a  number  of  cases  in 
which  the  appendix  invariably  pointed  south,  I  am  prepared 
to  say  that  when  pain  is  referred  to  the  left  side,  the  appendix 
occupies  the  pelvis.  Also,  that  when  in  these  suppuration  has 
taken  place,  resulting  in  a  large  pelvic  collection,  bilateral 
rigidity  of  the  abdominal  wall  is  always  pronounced.  When 
I  am  asked  to  see  a  patient,  the  diagnosis  of  whose  ailment  is 
not  clear,  with  a  history  of  the  three  cardinal  symj)toms,  with 
the  pain  referred  to  the  left,  rather  than  the  right  side,  with  a 
temperature  denoting  a  hectic  condition,  and  with  a  bilateral 
rigidity  of  the  lower  abdominal  w^alls,  I  am  convinced  that  it 
is  one  of  suppurative  appendicitis,  in  which  both  the  pus 
collection  and  the  appendix  occupy  the  pelvis.  An  illustrative 
case  is  the  following : — 

During  the  past  summer  I  was  asked  to  see  Miss .     About  two  weeks 

previously  she  had  been  suddenly  attacked  by  what  was  at  first  supposed  to  be 
acute  indigestion,  which,  however,  did  not  yield  to  the  ordinary  remedies.  In 
view  of  the  fact  that  the  spleen  was  enlarged,  characteristic  spots  present,  and 
the  temperature  suggestive  of  an  irregular  type,  a  i:)rovisional  diagnosis  of 
typhoid  fever  had  then  been  made.  But  the  suddenness  of  onset,  accompanied 
by  acute  abdominal  pain,  with  decided  bilateral  rigidity  of  the  lower  abdomi- 
nal walls,  the  temperature-record,  the  vaginal  and  rectal  examinations,  which 
excited  great  pain,  with  the  characteristic  fulness,  stamped  the  case  one 
of  suppurative  appendicitis  with  a  pelvis  full  of  pus.  I  advised  immediate 
operation.  Adverse  opinion  of  other  counsel  caused  a  delay  of  two  days, 
when  upon  operation  a  large  collection  of  foul  pus  was  found,  the  appendix, 
which  was  perforated  and  gangrenous,  occupying  the  pelvis.  The  appendix 
was  removed  and  recovery  was  uneventful. 

Under  these  circumstances  rectal  or  vaginal  examination 
will  demonstrate  a  sense  of  fulness.  The  contrast  between 
this  condition,  and  that  of  suppuration  in  the  pelvis  dependent 
upon  infection  of  any  of  the  uterine  appendages,  will  be 
discussed  later. 


DIAGNOSIS.  89 

In  almost  all  cases  of  appendicitis  there  will  be  more  or 
less  rigidity  of  the  lower  abdominal  walls.  Simple  pressure 
with  the  tips  of  the  finger  will  demonstrate  it.  In  the 
majority  of  cases  it  will  be  found  more  marked  over  the  right 
iliac  fossa ;  in  others,  if  the  pain  is  referred  to  the  left  side, 
the  rigidity  will  be  more  pronounced  there.  When  the 
appendix  occupies  the  pelvis,  and  is  the  seat  of  a  pus  col- 
lection, there  will  be  bilateral  rigidity. 

Fulness. — In  the  early  period  of  the  affection,  little,  if  any, 
fulness  in  the  right  iliac  fossa  is  observed.  It  appears  late  in 
the  course  of  the  disease,  after  inflammatory  exudate  has 
been  thrown  out  and  adhesions  have  been  formed.  In  con- 
nection with  this  fulness,  there  may  be  a  doughy  feeling,  or 
even  oedema,  both  of  which  may  be  indicative  of  pus,  although 
excessive  tenderness  is  a  more  reliable  sign.  CEdema  of  the 
abdominal  walls,  with  symptoms  of  another  disease,  may  lead 
to  the  false  impression  that  the  seat  of  the  trouble  is  not  in 
the  appendix,  as  is  shown  by  the  subjoined  instance : — ^ 

Miss  H.  was  attacked  ten  days  prior  to  examination.  She  had  had  the 
usual  symptoms  of  acute  appendicitis,  but  owing  to  slight  jaundice,  and 
decided  oedema  of  the  parts  overlying  the  hepatic  region  and  the  lower  right 
chest,  there  was  some  doubt  in  the  mind  of  the  attending  physician  as  to  the 
location  of  the  inflammatory  process.  Upon  pressure  there  was  more  pain 
over  the  oedematous  area  than  over  the  normal  position  of  the  appendix. 
After  considering  the  character  of  the  symptoms  from  the  beginning  of  the 
attack  I  concluded  that  purulent  appendicitis  was  present,  and  that  the  organ 
was  located  post-caecal,  pointing  north.  Operation  confirmed  this  diagnosis. 
The  appendix,  gangrenous  and  separated  from  the  caecum,  was  post-caecal  and 
surrounded  by  a  collection  of  pus  extending  upward  behind  the  liver  and 
inward  to  the  vertebral  column.     Recovery  followed. 

With  the  development  of  any  fulness  or  bulging,  the  con- 
tour of  the  abdomen  becomes  asymmetrical.  The  bulging 
may  at  tirnes  be  found  to  the  outer  side  of  the  right  rectus 
muscle,  caused  by  a  distended  csecum  floating  over  an  encysted 
abscess ;  or  at  times  fulness  will  be  found  above  the  outer  half 


90  APPENDICITIS. 

of  Poupart's  ligament,  due  to  the  presence  of  pus,  exudate, 
or  inflated  bowel. 

Late  in  the  attack  I  have  noticed  a  prominent,  rounded 
swelling  immediately  above  the  symphysis  pubis;  operation 
has  proved  this  to  be  a  collection  of  pus. 

Distention. — In  the  beginning  of  an  attack  of  appendicitis 
there  is  little,  if  any,  distention,  and  in  favorable  cases  the 
disease  may  terminate  with  no  distention  whatever.  Gener- 
ally, however,  in  the  later  stages  of  the  disease,  we  find  either 
localized  or  general  distention.  It  may  be  caused  by  mechani- 
cal obstruction  of  the  bowel,  by  adhesions,  or  by  kinking  of 
the  bowel  itself.  Localized  distention  is  due  to  a  localized 
peritonitis,  with  paralysis  of  the  bowel  in  the  affected  portion. 
When  distention  becomes  general,  and  is  not  due  to  mechanical 
causes,  it  probably  results  from  paralj'sis  caused  by  irritation 
of  Auerbach's  plexus,  or  from  a  general  peritonitis.  Marked 
constipation  and  the  use  of  opium  also  cause  distention,  and 
thus  hinder  recognition  of  the  true  condition.  By  ausculta- 
tion, we  may  generally  distinguish  functional  from  paralytic 
distention,  peristaltic  rumblings  being  heard  in  the  former 
but  not  in  the  latter  variety.  In  cases  of  profound  septic 
infection,  consequent  upon  a  purulent  peritonitis,  we  may,  at 
times,  find  a  scaphoid  condition  of  the  abdomen  due  to  com- 
plete paralysis  of  the  bowel. 

The  Presence  of  a  TuTnor. — In  many  cases  it  is  impossible  to 
determine  the  existence  of  tumescence,  owing  to  marked 
rigidity  of  the  abdominal  wall  and  excessive  pain  ;  rigidity, 
however,  should  never  be  mistaken  for  a  tumor.  Althougli  it 
has  been  claimed  that  a  tumor  can  be  found  in  every  case  of 
appendicitis,  such  is  not  my  experience.  The  csecum  is  never 
the  seat  of  a  collection  of  faeces,  and  this  fact,  together  with  the 
knowledge  that  the  appendix  is  not  much  enlarged  at  the 
onset  of  the  attack,  is  sufficient  in  most  cases  to  disprove  the 


DIAGNOSIS.  .  91 

presence  of  a  tumor.  After  the  disease  has  somewhat  ad- 
vanced, with  exudate  and  adhesions  present,  a  distinct  tumes- 
cence may  usually  be  diagnosticated  by  palpation.  But  if  the 
appendix  hold  the  pelvic  position,  abdominal  palpation  will, 
with  few  exceptions,  fail  to  reveal  an}"  tumor  whatever.  In 
these  cases  a  rectal  or  vaginal  examination  may  be  the  means 
of  discovering  a  mass.  When  the  appendix  is  located  in  the 
abdominal  cavity,  its  position  can  generally  be  determined, 
especially  if  the  disease  has  progressed  so  far  as  localized  peri- 
tonitis. Thick  abdominal  walls  or  the  destruction  of  the  ana- 
tomic relations  by  excessive  tympanites  might  cause  some 
difficulty.  Another  condition  that  might  hinder  the  location 
of  an  appendiceal  mass  would  be  a  post-csecal  position  of  the 
appendix,  with  rigidity  of  the  abdominal  muscles  and  disten- 
tion of  the  bowel. 

The  presence  of  inflammatory  exudate  presents  to  the  pal- 
pating fingers  a  hard,  unyielding  mass,  wdiich  I  believe  has  been 
frequently  mistaken  for  an  accumulation  of  fseces  in  the  cgecum. 

It  is  exceptional  for  a  chill  to  mark  the  advent  of  pus- 
formation  in  appendicitis — this,  despite  the  widespread  belief 
among  physicians  that  the  absence  of  a  chill  precludes  the 
possibility  of  suppuration. 

Coincident  with  the  onset  of  an  acute  attack  there  is 
always  a  rise  of  temperature,  similar  to  that  observed  in  all 
acute  septic  conditions.  This  is  more  marked  in  children. 
In  the  diagnosis  of  appendicitis,  however,  the  temperature  is 
so  variable  that,  except  in  making  a  differential  diagnosis,  it 
is,  as  a  guide,  of  little  value. 

The  Respiration. — As  a  rule,  the  breathing,  in  acute  appendi- 
citis, becomes  shallow  or  even  thoracic,  and,  if  general  peri- 
tonitis supervene,  is  markedly  so.  An  attempt  to  take  a  full, 
deep  breath  causes  severe  pain,  clearly  showing  itself  by  the 
expression  of  the  face. 


92  APPENDICITIS. 

Sudden  contraction  of  the  abdominal  walls,  consequent  upon 
an  effort  to  cough,  will  excite  pain  over  the  affected  area. 

Summary. 
Diagnosis,  "  three  cardinal  symptoms,"  viz. : — 

1.  Sudden  acute  pain  in  one  previously  well. 

2.  Unilateral  rigidity  of  lower  abdominal  wall. 

3.  Tenderness  over  site  of  appendix. 

After  onset,  tenderness  on  pressure  soon  becomes  localized 
and  corresponds  approximately  to  degree  of  inflammation. 
Location  of  tenderness  usually  over  McBurney's  point,  but 
varies  with  position  and  condition  of  appendix. 

Rectal  or  vaginal  examination,  or  both,  should  always  be 
made,  particularly  in  those  cases  in  which  abdominal  palpa- 
tion gives  negative  results.  In  these,  rectal  examination  dem- 
onstrates points  of  marked  tenderness,  sometimes  fulness.  Is 
of  greatest  value  when  appendix  points  south. 

Tenderness  increased — 

1.  Early  pus  formation. 

2.  Gangrenous  change. 

3.  Perforation. 
Tenderness  decreased — 

1.  Discharge  of  fsecal  concretion, 

2.  After  free  evacuation. 

3.  In  late  pus  cases  with  enough  septic  absorption  to 
paralyze  nerve  filaments. 

Abrupt  cessation  of  pain  indicates  gangrene. 

Pain  and  Tenderness  on  left  side  :  appendix  points  south 
(rarely  east)  and  occupies  pelvis.     Vesical  symptoms  common. 

Pain  on  left  side  with  tenderness  over  pubis :  appendix 
points  south ;  tip  of  appendix  affected  and  contains  pus. 

Pain  on  left  side  with  bilateral  rigidity:  appendix  points 
south  with  pus  collection  surrounding  it. 

Pain  over  hepatic  or  right  renal  region  with  tenderness  over 
course  of  ascending  colon :  appendix  lies  post-csecal  or  post- 
cfecal  and  post-colic,  and  points  north. 

Fulness  appears  late,  after  pus  formation. 

Excessive  tenderness  most  reliable  sign  of  pus. 


DIAGNOSIS.  93 

Distention : — (a)  Localized — is  due  to  localized  peritonitis. 
(6)  General : — 

1.  Constipation. 

2.  Opium. 

3.  Paralysis  of  intestines. 

4.  Mechanical  obstruction. 

5.  General  peritonitis. 

Tumor  is  often  impossible  to  detect  on  account  of  tenderness 
and  rigidity.  When  adhesions  and  infiltrations  are  present 
detection  usual.  Rectal  examination  often  successful  when 
abdominal  palpation  is  of  no  avail. 

Chill  is  rare  in  denoting  pus  formation. 


DIFFEREl^TIAL  DIAGl^OSIS. 

TYPHOID  FEVER. 

There  are  several  diseases  which  may  be  mistaken  for 
appendicitis,  chief  among  which  are  typhoid  and  the  various 
affections  of  the  genito-urinary  tract.  Some  of  the  rarer  cases 
in  which  a  differential  diagnosis  is  difficult  wdll  be  touched 
upon  below. 

Typhoid  fever  and  appendicitis  are  most  frequently  sources 
of  diagnostic  perplexit}'-, — so  much  so,  indeed,  that  upon  more 
than  one  occasion  I  have  seen  the  surgeon  forced  to  defer  ope- 
ration in  appendicitis,  because  the  opinion  of  the  majority  of 
the  medical  attendants  was  opposed  to  such  a  procedure,  they 
holding  the  case  to  be  one  of  typhoid  fever.  Yet  in  the 
early  stages  of  the  two  affections  the  characteristic  symptoms 
are  distinct.  The  sudden  onset  in  one  previously  well,  the 
rigidity  of  the  right  lower  abdominal  wall,  and  the  tenderness 
limited  to  the  position  of  the  appendix,  are  collectivel}^  pathog- 
nomonic of  appendicitis.  In  typhoid  fever,  the  slow  onset 
attended  by  lassitude,  the  headache,  the  epistaxis,  the  tempera- 
ture record  ;  the  diffused  abdominal  tenderness  with  the  re- 
laxed condition  of  the  abdominal  walls,  the  enlarged  spleen, 
and  the  absence  of  rigidity  should  be  sufficient  to  establish  a 
differential  diagnosis  with  absolute  certainty.  If,  in  connec- 
tion with  these  differential  points,  a  digital  examination  of  the 
rectum  demonstrates  a  sensitive  mass,  then  any  doubt  of  ap- 
pendiceal inflammation  should  be  at  once  dispelled.  Spots 
may  be  found,  but  they  are  not  of  absolute  diagnostic  value, 
since  they  may  be  present  or  absent  in  both  affections  and  are 
in  each  due  to  sepsis. 

94 


DIFFERENTIAL     DIAGNOSIS.  95 

Follicular  abscesses  of  the  appendix  are  responsible  for  some 
mistakes  in  the  differential  diagnosis  between  appendicitis  and 
typhoid.  The  minuteness  of  the  collections  account  for  the 
mildness  and  the  j)rolongation  of  the  sepsis,  and  the  lessened 
degree  of  the  local  symptoms.  In  this  type  of  appendicitis  we 
have  a  constant  source  of  absorption  with  a  small  amount  of 
tissue  involved.  The  temperature  record  and  the  general  con- 
dition in  such  cases  in  many  respects  closely  simulate  irregular 
typhoid,  and  much  care  in  examination  is  essential,  since  it  is 
not  uncommon  to  find  supposed  typhoid  fever  cases  in  which 
operation  has  demonstrated  the  presence  in  the  appendix  of 
macroscopic  follicular  abscesses,  varying  in  size  from  a  millet 
to  a  mustard  seed,  an  eroded  mucous  membrane,  and  a  more  or 
less  infiltrated  organ. 

The  points  to  be  borne  in  mind  in  making  a  differential 
diagnosis  between  appendicitis  and  the  later  stages  of  typhoid 
are  of  sufficient  distinctness,  but  each  symptom  must  be  con- 
scientiously studied.  The  early  history  and  the  local  symp- 
toms on  the  one  hand;  the  general  abdominal  and  mental 
symptoms,  with  dry  tongue,  and  the  temperature  record  on  the 
other,  are  quite  sufficient  to  make  differentiation  clear  and  dis- 
tinct. The  spleen  is  enlarged  in  both  affections.  The  enlarge- 
ment, however,  due  to  septic  infection  from  an  active  suppura- 
tive process  like  appendicitis,  is  apt  to  be  associated  with  pain 
caused  by  a  peri-sj^lenitis.  Difficulty,  however,  exists,  and  the 
following  case  is  related  to  illustrate  the  fact  that  follicular 
abscesses  in  the  appendix  are  capable  of  causing  a  train  of 
symptoms  which  suggest  typhoid  fever  : — 

Dr.  M.  consulted  me  about  his  little  girl,  because  the  uature  of  her  illness 
was  not  clear  to  him.  He  related  to  me  the  histoiy  of  the  case  and  showed 
me  the  temperature  record.  I  suggested  that  the  symptoms  resembled 
those  of  subacute  appendicitis.  An  appointment  was  made  with  a  physician, 
one  of  my  assistants,  and  Dr.  F.  of  the  German  Hospital.  In  consultation 
the    following    conditions    were    noted :    there    had    been    slight    epistaxis 


96  APPENDICITIS. 

about  seven  days  previous  to  date  of  examination  ;  the  temperature  record 
was  irregular,  dropping  suddenly  on  the  fifth  day  from  103  degrees  to  normal. 
The  tongue  was  dry  and  coated,  with  red  borders,  and  while  headache  was 
present  the  mental  condition  was  quite  clear.  The  spleen  was  somewhat 
enlarged,  and  on  the  abdomen,  which  was  slightly  tympanitic,  were  noticed 
some  indistinct  rose-coloted  spots.  Only  very  careful  questioning  of  the 
mother  elicited  the  fact  that  the  child  had  been  ailing  for  several  months  with 
digestive  troubles,  which,  never  severe,  had  always  yielded  to  a  purgative  dose 
of  castor  oil.  Examination  of  the  right  ihac  fossa  demonstrated  distinct  ten- 
derness, also  gurgling.  No  mass  could  be  made  out.  One  of  the  consulting 
physicians  inclined  to  the  diagnosis  of  typhoid  and  advised  delay.  The  two 
other  consultants  diagnosed  appendicitis,  basing  their  conclusion  on  the  pre- 
vious history,  the  absence  of  mental  symptoms,  and  the  distinct  tenderness 
in  the  right  iliac  fossa.  On  the  following  day  I  saw  the  case,  with  permission 
to  operate  if  I  concurred  in  the  diagnosis  of  appendicitis.  This  I  did,  and 
operated  at  once.  The  following  conditions  were  found  :  The  appendix  was 
situated  behind  the  colon,  to  which  it  was  adherent ;  the  mucous  lining  of  the 
tip  of  the  appendix,  which  was  club-shaped,  contained  several  follicular 
abscesses,  the  largest  of  which  was  the  size  of  a  split  pea.  Recovery  was 
uninterrupted  and  rapid.  The  symptoms  which  had  suggested  typhoid  dis- 
appeared immediately  after  the  removal  of  the  appendix. 

Before  directing  attention  to  the  points  of  differentiation 
between  appendicitis  and  the  affections  attended  with  pus 
formation  which  may  be  confounded  with  it,  I  desire  to  say 
that  the  occasion  for  having  to  make  a  differential  diagnosis 
between  appendicitis  with  pus  formation  and  other  forms  of 
pus  collection  should  never  arise,  as  in  all  cases  of  appendi- 
citis, the  appendix  should  be  removed  before  pus  has  formed. 


PYO-SALPINX  AND  OVARIAN  ABSCESS. 

The  presence  in  the  recto-uterine  cul-de-sac  of  an  inflamma- 
tory mass  in  intimate  relation  with  the  uterus,  which  renders  it 
partially  or  completely  immovable,  and  which  can  be  clearly 
outlined  by  vaginal,  bimanual,  or  combined  vaginal  and 
rectal  examination,  together  with  the  history  of  a  vagino- 
uterine  infection,  and  the  presence  of  a  septic  fever,  establish 
the  diagnosis  of  pyo-salpinx,  or  ovarian  abscess.  The  essential 
points  in  the  differentiation  between  these  two  affections  and 


DIFFERENTIAL    DIAGNOSIS.  97 

appendicitis   are   the    absence    of    the   history   of    the   three 
cardinal  symptoms  of  the  latter  affection. 

Inflammation  of  the  right  ovary  may  be  confounded  with 
appendicitis,  as  it  is  attended  with  pain,  tenderness  in  the 
right  iliac  fossa,  nausea,  and  fever.  It  is,  however,  always 
accompanied  by  disturbances  of  the  uterine  functions  and  is 
demonstrable  by  vaginal  or  bimanual  examination.  The  ten- 
derness is  never  so  intense  as  in  appendicitis  and  is  not  accom- 
panied by  a  perceptibly  enlarged  appendix. 

SUPPURATING  OVARIAN  CYST. 

An  appendiceal  abscess  and  a  suppurating  ovarian  cyst  on 
the  right  side  present  some  symptoms  in  common  which  may 
give  rise  to  difficulties  in  diagnosis.  These  symptoms  are: 
painful  tumor  in  the  right  iliac  fossa,  which  may  be  made 
out  by  vaginal,  bimanual,  and  external  examinations ;  vague 
symptoms  of  septicaemia;  hectic  temperature,  and  history  of 
previous  gastric  and  urinary  irritation.  The  differences,  how- 
ever, are  marked  and  can  be  distinguished  by  careful  consider- 
ation. In  ovarian  cyst  the  onset  is  gradual  and  a  history  of 
some  infection  can  generally  be  elicited.  The  pain  is  constant 
and  of  a  dull  character ;  by  pressure  the  significant  "  ovarian 
pain  "  may  be  produced,  differing  from  the  colicky  appendiceal 
paroxysms.  The  rigidity  of  the  abdominal  wail  is  not  so 
marked  as  in  appendicitis,  while  the  tumor  itself  is  more  elastic, 
having  apparently  thinner  walls  and  a  more  regular  outline. 

FIBROID  TUMOR. 

Appendicitis  may  be  confounded  with  a  local  inflammation 
of  a  portion  of  the  broad  ligament  overlying  an  intralig- 
mentary  fibroid  tumor.  The  main  points  in  the  differential 
diagnosis  are  the  history  of  metrorrhagia ;  the  presence  of  a 
growth,  detected  upon  vaginal  examination;  the  tenderness 

7 


98  APPENDICITIS. 

and  pain,  which  is  elicited  by  bimanual  palpation,  and  which 
is  confined  to  the  part  of  the  wall  overlying  the  mass. 

EXTRA-UTERINE  PREGNANCY. 

The  history  in  these  cases  is  usually  that  of  partial  or  com- 
plete cessation  of  the  menstrual  flow  for  one,  two,  or  more 
periods,  generally  accompanied  by  other  symptoms  of  preg- 
nancy, with  collapse  supervening  upon  an  attack  of  acute 
abdominal  pain.  The  pain  is  long-continued  and  paroxysmal, 
but  not  colicky.  An  irregular,  bloody,  vaginal  discharge, 
generally  lighter  in  color  than  the  normal  menstrual  flow,  and 
containing  shreds  of  tissue,  portions  of  the  decidua,  is  present. 
Vaginal  examination  will  detect  a  tender  and  sensitive  mass 
in  the  cul-de-sac,  unless  the  pregnancy  be  an  abdominal  one. 
In  the  majority  of  these  cases  there  is  a  history  of  sterility  for 
five  or  six  years  previous  to  the  abnormal  conception. 

PAINFUL  MENSTRUATION. 

A  condition  which  may  be  misleading  in  the  differentiation 
from  appendicitis  is  the  sudden  onset  of  pain  occurring  in 
young  unmarried  women  of  a  neurotic  temperament  at  the 
ushering  in  of  the  menstrual  period.  The  onset  is  sudden,  the 
pain  is  paroxysmal  and  accompanied  by  nausea.  There  may 
be  more  or  less  rigidity  of  the  lower  abdominal  walls,  unilateral 
or  bilateral.  The  presence  and  the  degree  of  the  rigidity  of 
the  abdominal  walls  depends  upon  the  amount  of  congestion 
of  the  ovaries,  whether  one  or  both  be  involved.  The  pain,  at 
first  paroxysmal,  is  most  severe  during  the  first  day  of  the 
menstrual  flow.  After  this  it  may  become  continuous  and,  in 
some  instances,  lasts  during  the  entire  period.  The  tenderness, 
like  the  rigidity,  corresponds  to  the  amount  of  the  ovarian 
congestion.  If  Ijoth  ovaries  are  involved  the  tenderness  will 
be  bilateral. 


DIFFEKENTIAL     DIAGNOSIS.  99 

The  pain  at  the  onset  differs,  however,  from  that  of  appendi- 
citis, being  non-inflammatory  and  localized  from  the  begin- 
ning, while  in  appendicitis  there  is  general  abdominal  pain, 
which  later  becomes  localized  in  the  right  iliac  fossa,  while 
marked  intestinal  symptoms  are  present. 

MENOPAUSE. 

Some  women  during  the  climacteric  occasionally  com- 
plain of  symptoms  resembling  appendicitis.  They  suffer  from 
localized  pain  in  the  right  side,  gastric  and  intestinal  dis- 
turbances, and  irregular  temperature.  As  absence  of  the 
menstrual  flow  often  exists,  some  difficulty  may  be  experi- 
enced in  reaching  a  correct  diagnosis,  particularly  in  those 
cases  associated  with  obesity.  The  exact  condition,  however, 
may  be  established  by  careful  inquiry  into  the  previous  his- 
torjT^  and  by  local  examination,  which  latter  means  demon- 
strates absence  of  rigidity  of  the  abdominal  walls  and  no 
palpable  swelling  about  the  appendix.  The  flushes,  back- 
aches, and  mental  symptoms  incident  to  the  menopause  will 
clear  up  the  diagnosis.  In  this  connection,  hysteria  may  be 
alluded  to,  particularly  as  appendicitis  gives  evidence  of 
becoming  a  '  fashionable '  disease.  The  mere  mention,  how- 
ever, of  the  nervous  affection,  with  its  ubiquitous  symptoms, 
will  suffice. 

FLOATING  KIDNEY. 

Floating  kidney  is  differentiated  from  appendicitis  by  the 
absence  of  the  three  cardinal  symptoms  and  of  fever,  by 
depression  in  the  right  flank,  by  the  presence  of  a  movable 
tumor,  characteristic  in  shape,  which,  by  properly  directed 
pressure,  can  be  restored  to  its  normal  position.  This  con- 
dition occurs  most  commonly  in  emaciated  females  of  a 
neurotic  temperament. 


100  APPENDICITIS. 

FLOATING  KIDNEY,  WITH  A  TWISTED  PEDICLE. 

From  floating  kidney  with  a  twisted  pedicle,  appendicitis 
may  be  diagnosticated  by  pain  which  radiates  in  the  line  of 
the  ureter,  is  not  increased  to  any  marked  degree  by  pres- 
sure ;  by  the  absence  of  rigidity  of  the  abdominal  wall ;  by  a 
history  of  a  movable  tumor  prior  to  the  attack ;  by  a  depres- 
sion in  the  right  loin  corresjDonding  to  the  site  of  the  kidney ; 
by  the  presence  of  blood  in  the  urine,  and  possible  symptoms 
of  uraemia. 

NEPHRITIC  COLIC. 

Ordinarily,  it  should  not  be  difficult  to  differentiate  be- 
tween nephritic  colic  and  appendicitis,  but  misleading  conclu- 
sions may  be  reached,  owing  to  the  fact  that  in  exceptional 
cases  of  appendicitis  there  exist  together  pain  referred  to  the 
umbilicus,  retraction  of  the  testicle  associated  with  vesical 
tenesmus,  and  painful  and  frequent  micturition.  Error,  how- 
ever, can  only  occur  in  the  early  stages  of  appendicitis,  as  the 
symptoms  later  on  are  entirely  dissimilar. 

Renal  colic  is  usually  ushered  in  by  a  distinct  chill,  followed 
by  excruciating  pain  in  the  loin  posteriorly,  which  is  relieved'" 
by  pressure.  This  pain  radiates  along  the  course  of  the  ureter 
and  is  much  diminished  by  the  voiding  of  urine,  which  often 
amounts  to  large  quantities.  In  appendicitis,  the  pain  at  the 
onset  is  more  diffused,  is  increased  by  pressure,  and  is  in  no 
way  affected  by  micturition.  In  renal  colic  there  is  no  rigidity 
of  the  abdominal  wall,  no  tender  mass  in  the  right  iliac  fossa 
can  be  palpated,  and  urine  examination  shows  characteristic 
alterations,  e.  g.,  uric  acid  or  phosphatic  deposits,  blood,  etc. 

I  recall  the  case  of  a  physician,  in  which  the  diagnosis  of  renal  cohc  had 
been  made,  and  in  which  the  ureter  was  supposed  to  have  been  ruptured  by 
the  passage  of  a  calculus.  The  autopsy  revealed  a  gangrenous  and  perforated 
appendix  with  diffuse  suppurative  peritonitis. 


DIFFERENTIAL     DIAGNOSIS.  101 

PYO-NEPHROSIS. 

From  abscess  of  the  kidney  appendicitis  diflfers  in  that  the 
pain  in  the  former  radiates  to  the  groin  and  testicle  with 
retraction  of  the  latter  organ.  Tenderness  is  elicited  on  pres- 
sure over  the  kidney.  There  is  irritability  of  the  bladder  and 
diminished  excretion  of  urine,  which  contains  pus  and  possibly 
blood.  In  the  absence  of  urinary  symptoms,  abscess  of  the 
kidney,  and  particulary  if  it  be  a  floating  kidney,  necessarily 
presents  greater  difficulty  in  dilEferentiation.  In  the  latter 
instance,  however,  the  tumor  will  be  movable.  I  have  recently 
operated  on  a  case  of  acute  suppuration  of  the  kidney  in  which 
the  urine  was  normal,  and  the  diagnosis  was  made  on  the 
anatomic  situation  of  the  swelling.  Nausea,  sometimes  with 
vomiting,  is  a  fairly  constant  symptom  in  the  renal  cases, 
though  of  not  much  diagnostic  value. 

PERI-NEPHRITIC  ABSCESS. 
When  the  appendix  holds  a  retro-csecal  position  or  occupies 
a  deep  ilio-csecal  fossa,  together  with  the  formation  of  pus,  it 
may  be  mistaken  for  a  peri-nephritic  abscess,  but  the  absence  of 
intestinal  disturbance  and  of  the  cardinal  symptoms  of  appen- 
dicitis will  be  sufficient  to  clear  up  the  diagnosis. 

GROWTHS  OF  THE  KIDNEY. 

Neoplasms  of  the  kidney  are  detected  by  palpation  of  the 
loin  space,  absence  of  inflammatory  symptoms,  continuous 
dull  pain,  frequent  micturition,  hsematuria,  and  pyuria.  Cysto- 
scopic  examination  of  the  bladder  with  catheterization  of  the 
ureters  may  be  necessar}^ 

URETERITIS. 

Inflammation  of  the  ureter  occurs  as  a  sequela  to  inflam- 
mation of  the  bladder,  or  in  connection  with  tubercular  and 


102  APPENDICITIS. 

calculous  disease  of  the  kidney.  The  differential  points  are : 
the  history ;  the  presence  of  tenderness  at  the  bladder  extremity 
of  the  ureter,  as  made  out  by  vaginal  or  rectal  examination ; 
the  presence  of  deep-seated  tenderness  along  the  line  of  the 
ureter;  the  absence  of  rigidity  of  the  abdominal  walls,  and 
the  presence  in  the  urine  of  pus,  blood,  and  ureteral  epi- 
thelium. 

RENAL  IRRITATION  OF  APPENDICITIS. 

Too  much  stress  cannot  be  laid  upon  the  importance  of 
urinary  examinations,  not  only  in  the  supposed  kidney  affec- 
tions before  mentioned,  but  also  in  appendicitis. 

It  is  true  that  in  most  cases  of  appendicitis  examination  of 
the  urine  reveals  slight  abnormalities,  such  as  traces  of 
albumin,  cylindroids,  hyaline  casts,  renal  and  ureteral  epithe- 
lium, pus,  and,  rarely,  blood  corpuscles.  In  the  affection  in 
which  the  kidney  and  its  adnexa  are  primarily  involved  the 
urine  will  show  pathognomonic  peculiarities.  The  renal  irri- 
tation of  appendicitis  is  probably  due  to  disturbances  of  the 
sympathetic  nervous  system,  but  may  be  the  result  of  actual 
contact  of  the  appendix  and  some  part  of  the  urinary  tract. 
To  cite  an  extreme  case,  I  have  recently  operated  upon  a 
patient  whose  urine  contained  pus  and  epithelium  from  the 
pelvis  of  the  ureter.  There  was  present  a  swelling  in  the 
right  loin  accompanied  by  tenderness,  extending  in  the  direc- 
tion of  the  attachment  of  the  appendix,  and  the  history  of  the 
three  cardinal  symptoms  was  elicited.  I  opened  up  the  right 
iliac  fossa,  finding  the  appendix,  which  was  post-colic  and 
contained  pus,  pointing  north,  adherent  to  and  in  communi- 
cation with  the  pelvis  of  the  ureter,  through  which  the 
contents  of  the  appendix  were  being  emptied  into  the  bladder, 
thus  explaining  the  urinary  symptoms.  The  recovery  was 
uneventful. 


DIFFERENTIAL    DIAGNOSIS.  103 

INTESTINAL  OBSTRUCTION. 

In  intestinal  obstruction  the  onset  is  more  abrupt  than  in 
appendicitis,  and  the  pain,  remissive  in  character  and  of 
severer  type,  may  be  referred  to  the  seat  of  the  obstruction, 
or  more  commonly  to  the  umbilicus;  there  is  absolute  consti- 
pation and  inability  to  pass  flatus,  while  persistent  and  uncon- 
trollable vomiting  occurs  early  and  soon  becomes  fsecal.  The 
temperature  is  normal  or  subnormal,  until  the  advent  of  peri- 
tonitis. With  the  onset  of  peritonitis,  regurgitant  vomiting 
begins.  The  vomiting  becomes  fascal,  a  condition  that  rarely 
occurs  except  in  the  later  stages  of  appendicitis.  Intussuscep- 
tion is  the  most  common  form  of  obstruction  in  children, 
while  obstruction  from  bands  and  volvulus  is  more  common 
in  adult  life.  Tumors  from  these  forms  of  obstruction  are 
generally  to  the  left  of  the  linea  alba.  When  obstruction 
is  the  result  of  intussusception,  blood  and  mucus  will  be 
discharged  from  the  rectum,  and  upon  examination  through 
this  canal  a  tumor  ma}''  be  felt.  The  development  of 
peritonitis  in  acute  intestinal  obstruction  is  marked  by  great 
abdominal  distention.  Shock  and  collapse  appear  early  in 
obstruction.  Such  is  not  the  case  in  appendicitis,  unless  it  be 
of  the  fulminating  type,  and  even  then  collapse  appears  later. 

PERFORATION  OF  SOME  PART  OF  THE  ALIMENTARY  TRACT. 

This  can  only  occur  as  the  result  of  a  pre-existing  localized 
inflammatory  condition,  and  should  not  be  confounded  with 
the  perforation  of  an  inflamed  appendix,  as  perforation  the 
result  of  appendicitis  takes  place  as  a  sequence  to  the  three 
cardinal  symptoms. 

GASTRIC  ULCER. 

Rarely  appendicitis  and  gastric  ulcer  may  be  confounded, 
especially  when  both  have  become  chronic,  since  in  both  the 


104  APPENDICITIS. 

pain  is  similar  in  character  and  increased  by  pressure.  The 
location  of  the  painful  area  in  either  varies,  and  is,  therefore, 
not  an  absolute  guide  for  a  differential  diagnosis.  Gastric 
disturbances  are  common  to  both.  However,  the  mode  of 
onset  differs  in  the  two  affections,  gastric  ulcer  being  of  slow 
development,  while  even  in  chronic  appendicitis  a  history  of 
an  abrupt  onset  can  generally  be  obtained.  In  gastric  ulcer, 
the  relief  of  nausea  and  pain  by  vomiting,  the  appearance  of 
the  vomited  matter,  which  is  frequently  streaked  with  blood, 
and  the  occurrence  of  gastric  haemorrhage,  are  symptoms 
sufficiently  striking  to  distinguish  it  from  appendicitis.  In 
this  connection,  it  might  be  mentioned  that  diseases  of  the 
pancreas,  such  as  abscess,  cyst,  or  impaction  of  calculus, 
which  may  give  rise  to  symptoms  resembling  appendicitis, 
may  have  to  be  diagnosed  by  the  exclusion  of  the  latter. 


CANCEE  OF  THE  CJECUM. 
This  should  not  be  confounded  with  chronic  appendicitis. 
In  the  former  instance,  there  is  absence  of  inflammatory 
symptoms ;  palpation  reveals  the  presence  of  a  nodular  swell- 
ing of  slow  growth,  attended  by  progressive  loss  of  flesh ; 
the  disease  occurs  usually  late  in  life ;  there  is  absence  of 
marked  rigidity  of  the  overlying  abdominal  walls,  and  absence 
of  decided  tenderness.  When  the  disease  has  advanced  to  the 
extent  of  offering  an  obstruction  to  the  fsecal  circulation,  there 
will  be  attacks  of  diarrhoea,  associated  with  mucus  and  blood 
in  the  stools,  and  paroxysms  of  acute  abdominal  pain,  the 
result  of  peristaltic  action  of  the  bowel.  The  peristaltic  wave 
can  be  excited  by  manipulation  of  the  growth,  and  can  often 
be  seen  through  the  thin  abdominal  walls. 


TUBERCULAR   APPENDICITIS. 

H.  W. ,  aged  fourteen,  was  admitted  to  the  Grerman  Hospital  February  1 5, 
1896,  with  the  following  history  :  During  the  past  ten  months  he  had  had  six 
typical  attacks  of  appendicitis,  but  each  time  operation  had  been  refused.  On 
the  day  before  admission  he  had  complained  of  pain  in  his  right  side,  which 
had  rapidly  grown  worse  until  the  entire  abdomen  had  become  involved. 
When  examined  his  temperature  was  104f°  ;  pulse  rate  116;  his  abdomen 
was  enormously  distended,  tympanitic,  and  tender,  particularly  in  the  region 
of  the  appendix,  although  the  tenderness  here  was  less  marked  than  the 
amount  of  distention  seemed  to  warrant.  Rigidity  was  present  only  as  part 
of  the  general  distention  and  was  equally  distributed.  There  was  no  record 
of  tuberculosis  in  his  family  ;  an  area  of  dulness  was  found  in  his  left  lung 
posteriorly,  but  no  tubercle  bacilli  were  detected  in  the  sputum. 

On  the  day  after  admission  his  temperature  fell  to  101°,  rising  again  in  the 
evening  to  104°.  From  the  symptoms  a  diagnosis  was  made  of  tubercular 
appendicitis,  with  subsequent  involvement  of  the  general  peritoneum,  and 
operation  was  suggested  and  agreed  to. 

Operation  :  Upon  section  of  the  peritoneum  a  small  quantity  of  a  dark, 
odorless  fluid  escaped.  The  caecum  and  appendix  were  bound  together  in  a 
dense  mass  of  lymph  and  the  whole  covered  with  tubercular  patches,  which 
were  also  distributed  throughout  the  peritoneum.  The  cavity  was  irrigated, 
glass  drainage  introduced,  and  the  wound  closed.  Patient  died  two  months 
afterward. 


106 


Plate  XVI 


Tubercular  appeqdix 


The  white  spots  represent  nqiliary  tubercles. 


DIFFERENTIAL    DIAGNOSIS.  107 

DYSENTERY  AND  COLITIS. 

While  dysentery  may  resemble  some  of  those  rarer  and 
unfavorable  cases  of  appendicitis,  in  which  diarrhoea  with 
bloody  stools  and  tenesmus  are  added  to  the  three  cardinal 
symptoms,  yet  differentiation  can  be  established  by  local 
examination.  In  dysentery,  though,  there  is  diffused  abdom- 
inal pain,  there  is  no  localized  tenderness,  and  no  mass  is 
palpa])le.     With  respect  to  colitis  see  page  159. 

TUBERCULAR  PERITONITIS. 

The  early  stages  of  tubercular  peritonitis,  especially  in  cases 
in  which  the  appendix  is  perhaps  primarily  affected  by  the 
specific  bacilli,  offer  great  difficulty  in  diagnosis.  The  cardi- 
nal symptoms  of  appendicitis  may  be  present  and  the  endeavor 
must  be  to  diagnose  the  tubercular  nature  of  the  affection. 
Careful  examination  of  the  patient  for  infection  elsewhere,  e.  g., 
family  history,  sputum,  chest,  glandular  involvement,  bone 
and  joint  diseases,  may  lead  to  the  recognition  of  the  cause. 

The  hectic  temperature  and  night  sweats  may  be  of  value. 
However,  the  most  significant  symptom  is  the  presence  of 
ascites,  which  in  tubercular  peritonitis  appears  early  and 
amounts  to  a  considerable  quantity,  though  its  recognition  is 
often  obscured  by  the  intestinal  distention.  The  pain  and 
tenderness  usually  tend  to  diminish  with  the  increase  of 
abdominal  tumescence.  The  case  of  H.  W.  (Plate  XVI)  is  a 
typical  illustration  of  the  disease,  which  probably  originated  in 
the  appendix. 

SPLENIC  ABSCESS. 

This  rare  affection  may  sometimes  be  confounded  with  those 
exceptional  'cases  of  appendicitis  in  which  pain  is  referred  to 
the  left  hypochondriac  region.  In  both  there  are  gastric  dis- 
turbances,  pain,    tenderness    on    pressure,  rigidity  over   the 


108  APPENDICITIS. 

affected  area,  and  similar  irregularities  in  temperature.  The 
previous  histor}'-  of  the  two  diseases  is,  however,  unlike.  Trau- 
matism usually  plays  a  prominent  part  in  the  causation  of 
splenic  abscess,  this  being  rarely  the  case  in  appendicitis. 
Then,  too,  splenic  abscess  occurs  in  general  septic  infections 
and  in  those  constitutional  diseases  in  which  enlargement  of 
this  organ  takes  place  and  is  due  to  embolism  in  the  paren- 
chyma of  the  spleen.  In  neglected  cases  of  appendicitis 
splenic  abscess  is  a  grave  complication,  and  the  symptoms 
referable  to  the  spleen  may  then  predominate. 

HEPATIC  AND  PERI-HEPATIC  ABSCESS. 

Appendicitis  can  be  confounded  with  abscess  of  the  liver  or 
about  the  liver  only  when,  late  in  the  disease,  a  circumscribed 
collection  of  pus  is  in  close  relation  with  the  appendix  which 
holds  a  post-csecal  position  and  points  toward  the  liver.  The 
previous  history,  the  hectic  temperature  of  hepatic  or  peri- 
hepatic abscess,  and  the  absence  of  a  history  characteristic  of 
an  acute  appendicitis  will  be  sufficient  to  establish  the  diag- 
nosis. 

RUPTURE  OF  THE  GALL-BLADDER 
will  occasion  severe  pain,  rigidity  of  the  right  rectus  muscle 
and  of  the  flat  muscles  of  the  upper  abdominal  walls.  The 
symptoms  presented  may  be  so  similar  to  those  of  a  perforated 
appendix  that  an  operation  alone  will  reveal  the  true  state  of 
afl'airs.     A  previous  history  may  help  in  the  diagnosis. 

ABSCESS  OF  THE  ABDOMINAL  WALL. 
Between  abscess  of  the  abdominal  wall  and  appendiceal 
abscess  there  should  be  but  little  difficulty  in  arriving  at  a 
correct  conclusion.  If  the  collection  be  in  the  superficial 
fascia  it  will  be  circumscribed,  but  if  between  the  abdominal 
muscles  it  is  likely  to  be  diffused.     The  purely  local  character 


DIFFEEENTIAL     DIAGNOSIS.  109 

of  the  abdominal  abscess,  the  swelling  moving  with  the 
abdominal  walls,  the  absence  of  intestinal  symptoms,  the 
presence  of  local  and  constitutional  evidence  of  pus,  coupled 
with  the  history  of  the  case,  should  be  enough  to  render  a 
differential  diagnosis  possible. 

INCIPIENT  INGUINAL  HERNIA. 
What  must  not  be  confounded  with  the  discomfort  attendant 
upon  a  chronic  appendicitis  is  that  of  incipient  inguinal  hernia. 
I  have  frequently  met  with  cases  of  marked  intestinal  indiges- 
tion in  the  absence  of  a  palpably  diseased  appendix,  accom- 
panied b}^  more  or  less  discomfort  if  not  pain  in  the  lower 
abdomen,  described  in  some  instances  as  being  dragging  in 
character.  In  these  a  careful  examination  of  the  inguinal 
canal  showed  weakness  of  the  abdominal  walls  at  the  site  of 
the  internal  ring,  and  the  application  of  a  light  truss  was  soon 
followed  by  the  disappearance  of  all  symptoms. 

ENLARGED  MESENTERIC  GLAND. 

An  enlarged  mesenteric  gland  may  be  mistaken  for  the 
appendix  when  palpating  the  abdomen  in  cases  of  supposed 
appendicitis.  Their  presence,  however,  is  not  significant  unless 
accompanied  by  the  evidence  of  acute  inflammation. 

MESENTERIC  HEMATOCELE. 

As  a  result  of  traumatism,  rupture  of  the  mesenteric  blood- 
vessels sometimes  occurs,  followed  by  the  formation  of  a 
mesenteric  hsematocele.  Under  ordinary  circumstances  absorp- 
tion takes  place.  When  the  heematocele  undergoes  suppura- 
tion, symptoms  closely  resembling  chronic  appendicitis  may 
be  observed. 

But  by  bearing  in  mind  the  character  of  the  onset  and  the 
absence  of  the  cardinal  symptoms  of  appendicitis  a  diagnosis 
is  readily  made. 


110  APPENDICITIS. 

A  CIRCUMSCRIBED  COLLECTION  OF  PUS 

in  relation  with  the  iliac  artery  and  occurring  in  acute  or 
chronic  appendicitis  may  be  confounded  with  aneurism  of  that 
vessel.  Though  the  pus  formation  may  have  transmitted 
pulsation,  this  is  not  expansile  nor  accompanied  by  a  bruit. 

HIP-JOINT  DISEASE. 

The  presence  of  the  characteristic  deformity;  inability  to 
execute  the  normal  movements  of  the  joint ;  pain  referred  to 
the  knee ;  arching  of  the  lumbar  spine  when  the  limb  is 
brought  into  the  fully  extended  position,  and  absence  of 
intestinal  symptoms,  should  determine  the  diagnosis. 

PSOAS-ABSCESS. 

The  difficulty  attending  the  diagnosis  between  chronic 
appendicitis,  and  incipient  psoas-abscess,  that  is,  before  the 
pus  has  passed  any  distance  down  the  psoas-sheath,  I  have 
had  forcibly  brought  to  my  mind.  The  chief  points  in  favor 
of  a  forming  psoas-abscess  are  the  appearance  of  the  patient, 
usually  suggestive  of  tuberculosis;  the  information  to  be 
obtained  by  an  examination  of  the  spine;  a  complete  tem- 
perature record,  and  a  tendency  to  flexure  of  the  thigh  of 
the  affected  side.  While  the  flexure  of  the  thigh  may  be 
and  is  present  in  some  cases  of  chronic  appendicitis,  it  is, 
nevertheless,  a  far  more  frequent  accompaniment  of  psoas- 
abscess.  Palpation  will  in  the  great  bulk  of  cases  of  chronic 
appendicitis  determine  the  presence  of  enlarged  appendix, 
while  deep  pressure  over  the  right  iliac  fossa  will,  in  case  of 
psoas-abscess,  reveal  tenderness  of  the  psoas  muscle,  but  fail  to 
disclose  the  presence  of  either  enlarged  appendix  or  the 
characteristic  rigidity  of  the  flat  muscles  of  the  abdominal 
walls. 


DIFFERENTIAL    DIAGNOSIS.  Ill 

LUMBAR  ABSCESS. 
In  this  affection  the  liistory  of  spinal  disease,  the  position  of 
the  swelling,  the  oedema  of  the  overlying  tissue,  the  slow  onset, 
and  the  absence  of  acute  tenderness,  rigidity,  and  intestinal 
disturbances,  will  suffice  to  make  the  differential  diagnosis. 

PNEUMONIA  AND  PLEURISY. 

The  onset  in  these  two  diseases  is  sometimes  very  acute  and 
the  pain  in  the  side  so  severe  as  to  cause  rigidity  in  the  abdom- 
inal muscles.  If  the  right  side  be  affected,  the  diagnosis  is 
sometimes  quite  difficult,  especially  in  children,  who  are 
unable  to  exactly  describe  their  pain.  Careful  physical  exam- 
ination will,  however,  clear  up  the  diagnosis. 

BILIARY  COLIC  (Gall-Stones). 

The  diagnosis  between  biliary  colic  and  appendicitis  is  at 
times  difficult. 

The  onset  in  both  is  somewhat  similar,  namely,  acute  pain 
coming  on  suddenl}^  accompanied  by  persistent  vomiting, 
which  is  more  severe  and  prolonged  in  the  former  than  in  the 
latter  affection.  History  of  cases  will  generally  show  differ- 
ences sufficiently  marked  to  distinguish  the  two  diseases. 

Less  severe  attacks  of  biliary  colic  will  probably  have 
occurred  at  intervals  of  several  years,  accompanied  by  jaun- 
dice, which  later  almost  invariably  becomes  pronounced,  and 
with  characteristic  color  and  itchiness  of  the  skin  may  persist 
in  a  slight  degree  during  the  entire  interval  between  the 
attacks. 

Biliary  colic  is  frequently  ushered  in  by  a  chill.  Fever  is 
absent,  particularly  in  early  stages  of  the  disease.  The  bowels 
are  usually  constipated,  as  in  appendicitis;  when  moved,  how- 
ever, the  stools  have  a  dark  green  color  and  peculiar  mouldy 


112  APPENDICITIS. 

odor.  If  gall-stones  are  found,  as  is  frequently  the  case,  diag- 
nosis is  established. 

The  location  and  degree  of  pain  differs  from  that  of  appen- 
dicitis, being  in  biliary  colic  more  continued  and  severe,  and 
radiating  usually  from  the  lower  right  chest  margin  to  the 
umbilicus. 

While  in  later  stages  pain  may  become  constant,  and  involve 
the  whole  epigastric  region,  or  extend  even  lower,  it  will, 
nevertheless,  usually  at  intervals  of  two  or  three  days,  become 
localized  and  more  acute  in  the  region  of  the  gall-bladder. 

In  appendicitis  the  localization  of  pain  is  always  toward, 
if  not  directly  in,  the  right  iliac  fossa,  while  between  severe 
paroxysms  there  is  marked  tenderness  at  this  point,  and 
characteristic  rigidity  of  the  overlying  abdominal  wall. 


PROGNOSIS. 

The  prognosis  to  be  given  in  any  case  of  appendicitis  will 
depend  more  upon  the  form  of  treatment  instituted  at  the 
onset,  than  upon  any  other  factor. 

If  the  appendix  is  skilfully  removed  within  twenty-four 
hours  from  the  commencement  of  the  attack,  the  prognosis  is 
favorable,  and  recovery  will  ensue  in  nearly  all  of  the  cases. 
If,  however,  the  opium  treatment  is  resorted  to,  an  unfavorable 
termination  is  more  likely,  because  by  this  method  there  will 
be  an  apparent  amelioration  of  symptoms  and  the  attending 
physician  will  receive  the  false  impression  that  the  disease  has 
either  been  held  in  check  or  completely  cured.  It  is  much 
more  likely,  however,  that  the  disease  is  progressing  rapidly, 
and  the  attention  of  the  physician  will  be  at  length  attracted 
to  the  true  state  of  affairs  by  a  tympanitic  abdomen,  a 
"  leaky  "  skin,  and  a  running  pulse. 

It  is  true  that  some  cases  will  entirely  recover  by  medical 
treatment  (16  in  400,  according  to  Ribbert),  and  a  slightly 
greater  number  wdll  apparently  recover  from  an  attack.  But 
the  course  of  the  disease  is  so  variable  that  one  cannot  say 
positively,  or  even  with  a  slight  amount  of  assurance,  what 
case  will  recover,  so  long  as  the  diseased  appendix  remains 
within  the  abdomen.  The  exception  to  this  rule  is  found  in 
those  cases  which  respond  immediately  to  laxative  treatment. 
These  often  temporarily  recover  from  an  attack  without  opera- 
tive interference. 

Those  cases  which  apparently  recover,  but  still  have  tender- 
ness over  the  site  of  the  appendix,  often  lapse  into  chronic 
inflammation,  and  warrant  an  unfavorable  prognosis  as  long  as 
8  113 


114  APPENDICITIS. 

operation  is  deferred,  for  the  inflammatory  process  may  light 
up  at  any  moment  with  renewed  vigor,  and  jeopardize  the 
patient's  life. 

Rarely  we  find  the  inflammatory  process  so  fulminating  that 
a  widespread  purulent  peritonitis  develops  in  such  a  short 
time  that  the  surgeon  cannot  be  called  early  enough  to  prevent 
it.  The  prognosis  in  these  cases  is  less  favorable,  but  the 
patient's  chances  are  enhanced  by  immediate  operation. 

In  other  cases  there  may  be  a  thrombus  of  the  appendicular 
artery,  followed  by  sloughing  of  the  entire  organ,  and  the  con- 
sequent emptying  of  the  contents  of  the  caecum  and  appendix 
into  the  general  peritoneal  cavity.  Here  again  the  prognosis 
is  unfavorable,  but  surgical  interference  off'ers  the  only  hope. 
Fortunately  the  number  of  instances  in  which  the  above  con- 
ditions are  found  is  small,  and,  therefore,  the  general  prognosis 
in  cases  in  which  operative  treatment  has  been  immediately 
established  is  favorable. 

Why  the  prognosis  is  unfavorable  in  the  cases  not  treated 
by  operation  is  plainly  seen  by  reference  to  the  pages  on  the 
pathology  of  the  disease.  It  is  impossible  to  foretell  what  will 
be  the  outcome  of  any  attack.  Some  authorities  claim  that  95 
per  cent,  of  all  cases  will  recover  without  operation ;  I  cannot 
agree  with  this  statement.  Too  often  have  I  seen  cases  which, 
apparently  recovering,  or  seemingly  entirely  recovered,  had  in 
a  moment  lapsed  into  a  most  critical  condition.  As  far  as 
general  health  is  concerned,  I  believe  that  an  unfavorable 
prognosis  must  be  given  to  all  those  cases  of  apparent  recovery 
in  which  appendiceal  inflammation  has  become  chronic.  I 
consider  a  chronically  inflamed  appendix  a  menace  to  life  on 
account  of  the  indisputable  fact  that  an  acute  attack  is  liable 
to  supervene  at  any  time.  The  case  reported  on  page  126 
will  illustrate  this  point. 

Another  condition  to  be  considered  in  connection  with  the 


PROGNOSIS.  115 

prognosis  of  chronic  appendicitis  is  the  danger  caused  by 
adhesions  which  may  exist  between  the  appendix  and  the 
surrounding  structures,  or  between  the  csecum  and  the  bowel, 
or  between  adjacent  coils  of  the  intestine.  No  one  can  tell 
when  these  may  produce  mechanical  obstruction  of  the  bowels. 
Every  band  or  adhesion  formed  in  the  peritoneal  cavity 
makes  the  prognosis  more  unfavorable,  and  the  probable 
presence  of  these  adhesions  must  be  considered  in  giving  a 
prognosis. 

The  prognosis  to  be  given  after  or  during  an  operation  will 
depend  largely  upon  the  conditions  found.  If  there  is  a 
general  purulent  peritonitis,  with  "  leaky  "  skin  and  running 
pulse,  the  outlook  is  ominous.  If  the  pus  is  confined  to  the 
right  iliac  fossa  by  a  limiting  wall  of  lymph,  the  prognosis  is 
better,  but,  again,  it  will  be  modified  by  the  treatment  pre-, 
viously  instituted. 

The  prognosis  to  be  given  in  cases  complicated  by  abscess  of 
the  liver,  pyle-phlebitis,  phlebitis  of  the  veins  of  the  leg,  etc., 
must  be  modified  by  the  extent  and  intensity  of  the  compli- 
cations. 


TREATMENT. 

In  the  treatment  of  appendicitis  my  observation  has  forced 
me  to  the  conclusion  that  there  is  but  one  course  to  pursue 
in  order  to  obtain  the  best  possible  results,  viz.,  to  remove 
the  appendix  as  soon  as  the  diagnosis  has  been  made.  The 
appendix  should  be  removed  so  early  in  the  attack  that  there 
will  be  no  danger  of  septic  absorption,  purulent  peritonitis,  or 
perforation  supervening,  and  in  those  cases  of  a  fulminat- 
ing character  which  have  been  almost  instantaneous  in  their 
progress  from  the  initial  symptoms  to  the  inauguration  of  a 
purulent  peritonitis  from  perforation  or  gangrene  early  opera- 
tion is  positively  demanded.  Sometimes  it  is  impossible  to 
institute  early  operative  treatment  for  one  of  several  reasons  : 
the  patient  may  not  live  within  reach  of  a  competent  surgeon ; 
he  may  not  be  willing  to  have  this  treatment  carried  out  until  it 
has  become  evident  that  his  only  chance  of  recovery  is  by 
operation;  or  there  may  be  some  serious  underlying  con- 
dition, as  advanced  Bright's  disease,  diabetes,  tuberculosis, 
etc.,  which  would  forbid  active  measures.  Under  such  cir- 
cumstances, expectant  treatment  is  the  only  alternative.  This 
embraces  rest  in  bed,  the  judicious  administration  of  laxatives, 
restricted  diet,  and  the  alleviation  of  pain. 

At  the  onset  of  an  attack  presenting  symptoms  which  are  at 
all  suspicious  of  appendicitis,  the  patient  should  be  put  to  bed 
at  once  and  kept  there  until  the  disease  has  been  either  cured 
by  surgical  interference,  or  subdued  temporarily  by  medical 
treatment.  The  latter  consists  mainly  in  the  administration  of 
laxatives.  In  most  cases  castor-oil  should  be  given.  If  the 
nausea  and  vomiting  are  persistent,  or  if  the  stomach  will  not 

IIG 


TREATMENT.  117 

tolerate  castor-oil,  recourse  should  be  had  to  saline  cathartics 
or  calomel.  In  some  instances,  with  early  and  continuous 
nausea,  with  or  without  vomiting,  it  is  advisable  to  administer 
calomel  at  once,  and  thus  take  advantage  of  its  dual  action, 
i.  e.,  of  allaying  the  irritability  of  the  stomach  and  of  producing 
laxation.  The  best  method  of  administering  calomel  under 
these  circumstances  is  in  the  powdered  form ;  compressed 
tablets  or  triturates  are  popular,  but  they  are  not  as  service- 
able as  the  powder,  and,  particularly  if  not  freshly  made,  are 
not  only  insoluble  and  inert,  but  also  liable  to  cause  mechan- 
ical irritation  of  the  stomach  and  provoke  further  emesis. 
The  addition  of  a  little  bicarbonate  of  soda  will  hasten  the 
laxative  effect  of  the  calomel.  At  times  small  and  repeated 
doses  of  calomel  will  fail  to  alleviate  the  irritation  of  the 
stomach,  and  in  these  cases  I  have  found  that  a  solid  dose 
of  from  five  to  20  grains,  repeated  in  an  hour,  if  necessary, 
will  often  have  the  desired  effect.  If  the  nausea  still  persists, 
a  small  fly-blister,  applied  immediately  below  the  ensiform 
cartilage,  often  proves  of  decided  service. 

I  believe  that  laxatives  should  be  administered  in  the 
beginning  of  every  attack  of  appendicitis.  Diarrhoea  does  not 
act  as  a  contra-indication,  as  they  are  generally  as  urgently 
called  for  under  this  condition  as  under  the  opposite  one  of 
constipation.  I  give  a  laxative  with  threefold  purpose:  1. 
To  relieve  pain  by  clearing  the  intestinal  tract  of  all  irritating 
materials.  2.  To  diminish  the  virulence  of  the  attack,  as  I 
believe  the  presence  of  foreign  or  irritating  material  in  the 
intestinal  tract,  and  especially  in  that  portion  of  it  adjacent 
to  the  csecum  and  appendix,  has  a  favorable  influence  upon 
the  development  of  the  invading  micro-organisms.  3.  To  set 
up  an  active  peristalsis  in  the  intestine  and  the  appendix, 
and  so  help  the  latter  to  empty  itself. 

As  a  general  rule,  I  prefer  castor-oil,  because  it  unloads  the 


118  APPENDICITIS. 

bowel  of  faecal  matter  without  causing  an  outflow  of  serum 
from  the  intestinal  circulation.  Salts,  on  the  other  hand, 
cause  liquefaction  of  most  of  the  bowel  contents,  but  solid 
particles  of  faecal  matter  are  liable  to  remain.  In  the  later 
stages,  however,  where  peritonitis  has  developed  and  a  deple- 
tion of  the  intestinal  circulation  is  desirable,  salts  are  pre- 
ferable. 

I  am  perfectly  familiar  with  the  unfavorable  opinions 
of  a  number  of  other  writers  upon  the  advisability  of  the 
administration  of  laxatives  in  appendicitis,  but  my  experience 
has  taught  me  that  it  forms  the  only  successful,  and  there- 
fore justifiable,  treatment  when  operation  cannot  be  performed. 
I  do  not  hesitate,  therefore,  to  offer  it  to  my  readers  as  sound 
and  rational  therapeutics.  I  repeat  that  laxatives  should  be 
given  earl}^  and  in  sufficient  quantity  to  produce  thorough 
evacuation  of  the  bowel,  for  they  accomplish  the  most  good 
when  given  thus,  and  before  adhesive  inflammation  has 
resulted  in  a  matting  of  the  neighboring  coils  of  intestine, 
which  is  the  method  by  which  nature  imprisons  the  inflamed 
appendix,  and  tends  to  prevent  infection  of  the  peritoneal 
cavity  in  the  event  of  perforation.  I  am  certain  that  in  the 
presence  of  commencing  adhesive  inflammation  of  the  appen- 
dix and  its  neighborhood,  less  danger  attends  the  evacuation 
of  the  bowel  than  that  caused  by  a  full  bowel.  The  benefit 
of  unloading  the  bowel  far  outweighs  the  danger  of  breaking 
up  any  adhesions  that  may  be  forming.  In  the  later  stages 
of  the  disease,  after  the  barrier  which  protects  the  general 
peritoneal  cavity  from  the  inflamed  and  septic  appendix  has 
been  formed,  I  do  not  advise  active  purgation,  as  the  peristaltic 
contractions  will  tend  to  break  down  nature's  safeguard  against 
the  spread  of  the  affection. 

Of  all  the  therapeutic  agents  that  have  been  used  in  the 
treatment  of  appendicitis,  opium  is  the  one  which  has  been 


TREATMENT.  119 

most  often  responsible  for  the  mistakes  made  in  diagnosis,  for 
the  unsuspected  development  of  untoward  symptoms,  and  for 
the  call  for  the  surgeon  when  too  late.  There  is  a  percentage 
of  deaths  from  appendicitis  which,  beyond  doubt,  is  due  to  the 
indiscriminate  and  injudicious  use  of  this  drug. 

Opium  is  dangerous  in  the  treatment  of  this  disease  or  of 
any  intra-abdominal  inflammation,  because  it  hides  all  the 
symptoms  of  the  affection ;  it  blocks  up  the  bowels ;  it  causes 
distention  of  the  intestinal  tract,  and  very  often  adds  to  the 
nausea.  The  worst  objection  to  the  use  of  the  drug  is  its 
power  to  mask  all  symptoms,  and  too  much  stress  cannot  be 
laid  upon  this  point.  It  is  essential  that  there  should  be 
nothing  at  an}^  time  in  the  course  of  an  attack  of  appendicitis 
to  prevent  a  clear  conception  of  the  progress  of  the  disease.  In 
many  cases,  indeed,  the  symptoms  will  be  ameliorated  after  a 
free  evacuation  of  the  bowels.  On  the  other  hand,  there  are 
so  many  that  go  from  bad  to  worse,  that  we  must  be  always 
in  a  position  to  observe  symptoms  of  advancing  trouble,  which 
is  impossible  if  opium  is  given. 

One  of  nature's  most  reliable  signs  of  disease  is  pain, 
and  in  appendicitis  this  pain  is  generally  in  proportion  to 
the  degree  of  the  inflammation.  If  then  our  patient  be  dosed 
with  opium,  it  will  be  impossible  to  judge  what  is  taking 
place  within  the  abdomen ;  there  is,  even  for  a  short  time, 
freedom  from  pain,  which  gives  the  impression  that  the  disease 
is  progressing  favorably.  Possibly  it  may  be,  but  more  often 
we  find  that  the  very  case  that  is  so  quiet  and  restful  now  will 
shortly  be  writhing  in  agony  and  presenting  all  the  symptoms 
of  perforation  or  purulent  peritonitis.  The  surgeon  is  then 
called,  but  is  unable  to  tell  accurately  whether  the  distention 
of  the  bow^els  is  caused  b}^  peritonitis  or  by  opium  ;  the  patient 
is  drowsy  and  cannot  respond  intelligently  to  questions ;  the 
pain  is  alleviated  for  the  time,  and  the  presence  or  absence 


120  APPENDICITIS. 

of  tenderness  cannot  be  determined.  Had  laxatives  been 
given,  the  attending  physician  would  have  known  that  every 
symptom  appearing  was  due  solely  to  the  disease ;  that  dis- 
tention of  the  bowel  must  be  due  to  peritonitis ;  he  would 
probably  have  had  a  surgeon  in  counsel  days  before  the 
trouble  had  reached  such  a  stage.  It  is  true  that  there  is 
nothing  that  appeals  to  the  sympathies  of  a  doctor  more  than 
suffering,  and  it  is  natural  that  he  should  attempt  to  relieve  it 
at  once.  But  instead  of  giving  opium,  which  will  block  up  the 
bowels,  cause  the  retention  of  all  irritating  material,  and  mask 
all  symptoms,  he  should  order  a  laxative,  cause  free  evacuation, 
and  thus  remove  much  of  the  irritation  that  is  causing  pain. 

The  use  of  opium  to  the  exclusion  of  laxatives  is,  in 
my  opinion,  therefore,  unjustifiable,  most  dangerous,  and 
should  never  be  countenanced.  In  the  majority  of  cases,  after 
the  complete  evacuation  of  the  bowels  the  pain  subsides.  In  a 
few,  however,  the  pain  returns  with  renewed  vigor.  This  con- 
stitutes one  of  the  strongest  indications  for  operation,  as  it  de- 
notes perforation  of  the  appendix. 

The  use  of  such  remedies  as  veratrum  viride,  aconite,  fever 
mixtures,  etc.,  have  no  place  in  the  therapeutics  of  appendi- 
citis. The  only  remedies  locally  applied  that  have  any  bene- 
ficial effect  are  ice-bags  and  turpentine  stupes,  though  occa- 
sionally hot  applications  may  prove  more  grateful.  Dry  cold 
should  always  be  preferred,  as  it  acts  as  a  local  anaesthetic, 
modifies  the  degree  of  inflammation  if  applied  early,  and  thus 
hastens  resolution.  The  application  of  tincture  of  iodine, 
leeches,  and  blisters  is  especially  contra-indicated,  not  only 
because  they  do  no  good,  but  also  because  they  add  to  the 
patient's  discomfort.  Blisters  are  particularly  objectionable 
on  account  of  their  macerating  effect  upon  the  skin,  thus 
making  a  septic  field  for  operation.  The  latter  is  also  true 
of  leeches. 


TREATMENT.  121 

The  indications  for  enemata  are  the  same  as  for  the  ad- 
ministration of  laxatives  ;  they  should  be  given,  however,  only 
as  an  aid  to  the  laxative,  and  not  to  its  exclusion.  Forced 
enemata  should  never  be  given  to  overcome  the  constipation 
consequent  upon  a  paralytic  condition  of  the  intestine;  for 
obstruction  due  to  paralysis  usually  indicates  perforation  of 
the  appendix,  and  a  forced  enema,  under  such  conditions, 
may  be  emptied  into  the  peritoneal  cavity,  as  happened  in 
the  following  case : — 

Mr.  B. ,  twenty-seven  years  old,  was  seized  suddenly  with  cramp-like  pain 
in  the  abdomen,  accompanied  by  nausea  and  vomiting,  for  which  he  was  given 
morphia,  gr.  i,  by  his  physician.  The  pain,  nausea,  and  vomiting  immedi- 
ately ceased.  Twelve  hours  later  pain  reappeared  but  was  located  in  the 
right  iliac  fossa,  and  tenderness  upon  deep  palpation  could  be  elicited. 
There  was  but  a  shght  rise  in  temperature — 100°-101°,  pulse  96. 

His  condition  remained  unchanged  apparently  for  ten  days,  when  obstinate 
constipation  associated  with  tympanites  set  in.  Calomel,  Rochelle  salts,  and 
castor-oil  were  successively  administered  without  effect.  A  high  enema  was 
then  given,  very  little  returning  from  bowel.    Obstraction  of  bowel  diagnosed. 

Upon  examining  the  case  I  found  excessive  distention  of  the  abdominal 
walls,  which  were  extremely  sensitive  to  the  touch,  a  rapid  pulse,  temperature 
102°.  The  excessive  tympanites  precluded  palpation  of  the  abdominal  walls  ; 
examination  per  rectum  nil.  Diagnosis  from  history,  appendicitis  with  septic 
peritonitis  from  perforation. 

Operation  by  incision  through  right  semilunar  line.  Upon  opening  the 
peritoneum  a  large  quantity  of  pus,  faeces,  and  fluid  escaped.  Csecum  lifted 
up,  when  it  was  found  that  the  appendix  had  sloughed  off,  leaving  a  large 
ulcerated  opening  in  the  caecum  through  which  the  high  enema  had  been 
forced  into  the  abdominal  cavity,  possibly  at  the  same  time  tearing  the 
appendix  from  its  csecal  origin.  Opening  in  caecum  closed,  abdominal  cavity 
washed  out,  glass  drainage  introduced,  wound  closed. 

Result,  death  ;  patient  never  reacted  from  operation. 

Asafoetida  suppositories  are  useful  in  relieving  pain  and 
aiding  peristalsis. 

The  diet  in  all  cases  of  acute  appendicitis  should  consist 
of  liquid  foods,  such  as  broths,  the  main  object  being  to  give 
only  what- will  leave  little,  if  any,  residue  in  the  intestinal 
tract.  Beaten  eggs,  pancreatized  milk,  or  buttermilk  may  be 
ffiven. 


122  APPENDICITIS. 

In  cases  of  chronic  appendicitis,  the  patient  should  eat 
sparingly  and  avoid  all  foods  that  will  overload  the  bowels 
with  residue.  All  coarse  or  hard  foods,  such  as  grits,  coarse 
oatmeal,  tough  meats,  fibrous  vegetables,  etc.,  should  be  for- 
bidden. Fruits  which  do  not  contain  seeds,  and  from  which 
the  skin  has  been  removed,  may  be  eaten  without  danger. 

To  recapitulate :  In  acute  attacks,  when  operation  is  impossi- 
ble, the  following  measures  promise  the  best  results  :  Absolute 
rest  in  bed ;  liquid  diet,  as  peptonized  milk,  champagne, 
broths,  etc. ;  castor-oil  or  salts  or  calomel  in  small,  repeated 
doses.  Ice-bag  applied  locally.  Asafoetida  suppositories.  For 
persistent  nausea,  small  fly  blister  just  below  ensiform  cartilage. 

Although   there   may  be   a   few  cases   that   for  one  or  all 

of  the  reasons  stated  cannot  or  will  not  have  the  benefit  of 

early  operation,  yet  the  vast  majority  will  depend  upon  the 

physician  for  advice.     In  every  one  of  these,  unless  constitu- 

♦ 
tionally  contra-indicated,  I  believe  that  the  appendix  should 

be  removed  as  soon  as  the  diagnosis  has  been  established.     I 

recognize  the  fact  that  a  very  small  percentage  of  all  cases 

will  temporarily  recover  without  the  use  of  the  knife,  but  no 

one  can  tell  which  case  will  terminate  favorably  or  which  will 

go  on   to   perforation   and  gangrene,  with   the  train  of  fatal 

complications  that  is  liable  to  follow.     The  best  result  in  all 

cases  is  obtained  by  removal  of  the  appendix  in  the  beginning 

of  the  attack.     Appendicitis  is  a  surgical  affection,  and  should  be 

treated  as  such. 

The  first  question  that  arises,  after  the  diagnosis  has  been 

established,  is  concerning  the  character  of  the  attack  and  its 

probable  outcome.     It  is  here  that  we  come  against  the  stone 

wall  of  fact,  reinforced  by  logical  conclusions  founded  upon 

experience.    We  cannot  foretell,  with  even  the  slightest  amount 

of  assurance,  the   issue  of  any  attack  of  appendicitis.     The 

main  point  to   consider   is,  then,  shall    we  risk  the  patient's 


TREATMENT.  1 23 

life,  or  shall  we  accept  the  only  alternative  and  remove  the 
organ  in  its  incipient  inflammation  ?  In  this  affection  early 
operation  is  a  conservative  and  not  a  radical  procedure.  We 
are  not  governed  by  the  same  reasons  that  influence  us  to 
perform  the  radical  operation  for  the  cure  of  simple  hernia  or 
for  the  removal  of  the  uterus  for  a  fibroid.  In  appendicitis 
we  have  before  us  the  probable  consequences  of  suppuration, 
gangrene,  and  perforation.  The  proportion  of  cases  that  have 
but  one  attack,  remaining  perfectly  well  after  its  subsidence, 
is  so  infinitely  small,  compared  to  those  that  have  repeated 
attacks  with  an  interval  of  invalidism,  that  I  do  not  believe 
the  rare  exception  should  interfere  with  the  rule,  viz.,  that 
where  practicable  all  cases  of  appendicitis  should  be  operated 
upon  as  soon  as  the  diagnosis  has  been  established.  Of  course, 
I  do  not  include  cases  in  collapse. 

It  is  sometimes  advised  to  delay  operation  until  there  is 
evidence  of  pus,  and  that  if  there  is  any  doubt  as  to  pus  forma- 
tion the  operation  should  be  deferred.  I  could  cite  many  cases 
where  the  operation  was  delayed  until  there  was  unmistakable 
evidence  of  pus,  some  of  them  having  been  delayed  so  long- 
that  the  patient  was  moribund  when  the  surgeon  was  called. 
To  defer  operation  a  certain  number  of  days  or  even  hours  is 
to  expose  the  patient  to  risks  not  justifiable  in  the  light  of  the 
present  status  of  appendiceal  surgery.  The  best  results  and 
the  smallest  mortality  are  obtained  when  the  operation  is  per- 
formed at  the  earliest  possible  opportunity.  The  diagnosis 
can  and  should  be  made  in  a  few  minutes,  and  the  operation 
should  follow  as  soon  as  possible.  Why  should  we  wait  for 
the  formation  of  pus  with  its  dangerous  sequelae,  since  such  a 
condition  greatly  adds  to  the  dangers  of  an  operation,  particu- 
larly when  -that  greatest  of  all  absorbing  surfaces,  the  perito- 
neum, is  involved?  One  has  but  to  picture  to  himself  the  two 
operations,  one  for  the  removal  of  an  appendix  without  pus 


124  APPENDICITIS. 

formation,  the  other  the  removal  of  an  appendix  bathed  in 
pus,  to  arrive  at  the  only  reasonable  conclusion.  In  the  first 
case  we  have  a  clean  abdominal  incision ;  the  appendix 
readily  removed  and  the  stump  covered  with  a  serous  coat  and 
then  invaginated  into  the  walls  of  the  caecum ;  the  external 
wound  is  aseptically  closed.  In  the  second  case  we  open  up  a 
collection  of  fetid  pus  which  in  its  escape  comes  in  contact  with 
the  incision  and  its  contiguous  parts ;  we  remove  the  appendix 
under  unfavorable  circumstances  with  possibility  of  infecting 
the  general  peritoneal  cavity  ;  the  wound  cannot  be  closed,  but, 
instead,  must  be  drained  or  packed  with  gauze,  thus  risking  a 
subsequent  ventral  hernia.  With  these  pictures  in  mind,  I  can- 
not see  how  the  claim  is  tenable  that  it  is  better  to  wait  for 
pus  before  advising  operation.  That  delay  is  dangerous  in 
the  great  majority  of  cases  is  certain ;  that  a  few  cases  will 
recover  from  the  disease  (16  in  400,  according  to  Ribbert) 
cannot  be  denied ;  that  some  cases  will  have  a  subsidence  of 
acute  symptoms  must  also  be  granted ;  but  that  any  one  can 
foretell  the  outcome  I  most  emphatically  deny.  Those  men 
who  are  the  least  decided  upon  the  question  of  operation  are 
those  who  have  been  limited  in  their  experience.  One  must 
see  the  cases  in  all  stages  to  realize  the  dangers  of  delay ;  one 
must  observe  the  effects  of  the  various  methods  of  treatment  to 
be  convinced  that  there  is  but  one  sure  road  to  recovery, 
viz.,  early  operation. 

An  analysis  of  50  consecutive  cases,  selected  from  my  case 
book,  of  primary  attacks  of  appendicitis  in  which  operation 
was  performed,  will  illustrate  the  importance  of  the  position  I 
have  taken  in  reference  to  early  operation  in  this  class  of  cases. 

The  length  of  time  elapsing  between  the  onset  of  the  disease, 
as  reported  by  the  attending  physicians,  and  the  date  of  opera- 
tion varied  greatly : — 

5  were  operated  on  within  24  hours. 


TREATMENT.  125 

18  were  operated  on  within  48  hours. 
12  were         "  "         "      72  hours. 

1  was  "  "  "  4  days. 
3  were  "  "  "  5  days. 
9  were         "  "         "        6  days. 

2  were         "  "         "  7  to  9  days. 

Of  the  35  cases  operated  on  within  seventy-two  hours,  28,  or 
80  per  cent.,  recovered  and  seven  died. 

Of  the  remaining  15  cases  operated  on  between  the  third  and 
the  ninth  day,  ten,  or  66  per  cent.,  recovered  and  five  died. 

With  the  exception  of  faecal  concretions,  which  were  fre- 
quently met  with,  the  only  foreign  body  discovered  was  the 
accumulation  of  a  number  of  strawberry  seeds  in  one  case. 

In  those  cases  in  which,  for  some  reason,  the  operation  was 
not  performed  in  the  first  stages  of  the  disease,  and  where  the 
patient  apparently  recovers  from  the  attack — the  appendiceal 
inflammation  becoming  chronic  —  I  believe  the  appendix 
should  always  be  removed  between  the  attacks,  when  the 
disease  is  more  or  less  quiescent.  There  is  no  doubt  in  my 
mind  that,  without  exception,  every  appendix  that  has  been 
the  seat  of  an  inflammatory  process  is  a  source  of  danger  to 
the  life  of  the  patient,  liable  at  any  time  to  acute  inflamma- 
tion, and  should,  therefore,  be  removed.  The  mortality  from 
the  operation  in  chronic  cases  is  exceedingly  small.  In 
cases  of  so-called  recovery,  most  often  we  find  the  patient 
a  chronic  invalid,  with  constant  dread  of  another  attack, 
troubled  with  indigestion  and  obstinate  constipation  or 
diarrhoea.  We  must  also  consider  the  results  of  inflam- 
mation that  are  not  apparent  to  the  patient,  such  as 
bands  of  adhesions  that  are  liable  to  cause  mechanical  ob- 
struction or  chronic  inflammation,  that  may  spring  into 
activity  at  any  moment;  we  must  consider  the  effect  of  the 
previous  attacks,  with  the  resulting  mass  of  exudate  and  ad- 
hesions, binding  the  appendix  down  so  firmly  that  there  will 


126  APPENDICITIS. 

be  added  difficulty  and  corresponding  danger  wlien  the  organ 
is  removed.  That  grave  trouble  may  arise  in  a  chronically 
inflamed  appendix  at  any  time  is  well  illustrated  by  the  fol- 
lowing case : — 

Dr.  ,  while  witnessing  one  of  my  operations   for   the 

removal  of  the  appendix,  told  me  that  he  had  been  troubled 
with  a  chronic  appendicitis  for  some  time.  I  volunteered  the 
advice  that  he  should  have  the  appendix  removed,  and  he 
concluded  to  do  so  as  soon  as  he  could  arrange  his  business 
satisfactorily.  About  six  weeks  after  our  conversation  I  was 
telegraphed  for  to  come  to  his  home  at  once,  as  he  was  suffer- 
ing from  an  acute  attack.  On  my  arrival,  I  found  him 
suffering  from  purulent  peritonitis,  the  result  of  perforation. 
Operation  disclosed  the  belly  full  of  fetid  pus ;  the  peritoneum 
the  seat  of  a  most  virulent  form  of  inflammation;  the  ap- 
pendix gangrenous  and  perforated,  and  a  gangrenous  patch 
in  the  csecum.     Death  ensued  in  about  eight  hours. 

This  is  but  one  of  many  instances  I  have  seen,  and  it  is 
hardly  necessary  to  say  that  in  most  of  such  cases  operation 
promises  but  little. 

If  pus  has  formed  in  an  attack  of  appendicitis,  I  believe  it 
should  be  removed  at  the  earliest  possible  moment.  The  prac- 
tice of  deferring  operation,  in  the  presence  of  a  purulent  col- 
lection, for  a  few  days,  in  the  hope  that  the  limiting  membrane 
that  forms  the  partition  between  the  collection  and  the  general 
peritoneal  cavity  will  become  stronger,  is  a  procedure  which  I 
regard  as  unwise  and  attended  by  risks  both  immediate  and 
remote.  The  immediate  risks  are  from  general  septic  infec- 
tion, metastatic  abscess,  pyelo-phlebitis,  and  abscess  of  the 
liver.  The  remote  risks  are  gangrenous  perforation,  sponta- 
neous separation  of  the  appendix  from  the  ceecum,  spontane- 
ous separation  of  the  appendix  in  its  continuity,  or  necrosis 
and  perforation  of  the  csecum  from  pressure  of  the  collection 
against  its  walls. 


H.  W.,  age  twenty -five,  admitted  to  German  Hospital  January  15,  1896. 
Had  his  first  attack  ten  days  previous  to  admission,  with  sudden  onset  of  pain 
in  his  right  ihac  fossa  immediately  after  eating,  followed  by  rigidity  and 
marked  tenderness.  Remained  in  bed  two  days  and  symptoms  abated,  though 
there  was  still  pain  on  right  side,  which  increased  by  motion.  No  vomiting  ; 
constipation.  At  the  time  of  admission  he  had  the  following  symptoms  : 
Tenderness  on  pressure  over  McBurney's  point  and  marked  rigidity  on  right 
side  ;  by  deep  palpation  mass  could  be  made  out ;  tongue  coated  ;  tempera- 
ture normal. 

Operation. — The  apijendix  through  nearly  its  whole  length  lay  in  front  of 
the  csecum.  The  tip,  however,  was  adherent  to  the  posterior  surface  of  the 
caecum.  [See  Fig.  2,  page  129.]  It  was  covered  by  dense  adhesions,  upon 
the  loosening  of  which  about  one  pint  of  thick,  fetid  pus  was  discharged 
from  behind  the  caecum.  The  cavity  was  wiped  out  with  dry  gauze  (no 
irrigation) ;  the  appendix  was  freed  and  tied  oiF;  gauze  drainage  was  left  in 
and  the  abdominal  wound  closed. 

For  sixteen  hours  after  operation  the  patient  did  well  and  suffered  little. 
Suddenly  he  had  a  sharp  accession  of  pain  over  the  epigastrium,  was  nauseated, 
and  finally  began  vomiting  greenish  matter  in  which  blood  was  discernible. 
Distention  slight.  Wound  was  dressed,  gauze  taken  out,  and  cavity  cleansed. 
Delirium  set  in,  vomiting  became  continuous,  and  death  ensued  on  third  day 
after  operation. 

Post-Mortem. — Incision  closed  and  in  good  condition.  In  the  upper 
posterior  aspect  of  the  caecum  were  two  small  perforating  ulcers  surrounded 
by  necrotic  areas.     Cicatrix  of  appendix  amputation  scarcely  discernible. 


128 


Plate  XVII 


Perforations 
surrour^ded 
by       -.=-::::: 

qecrotic  area 


eo-caecal  valve 


*.— Lumeri  of   appendix 


TREATMENT. 


129 


In  these  cases  the  csecum  may  be  so  involved  from  pressure 
that  at  any  time  it  may  rupture  with  consequent  fsecal  fistula, 
opening  externally  or  into  the  peritoneal  cavity. 


Fig.  2. — Showing  Position  of  Appendix  in  Case  of  H.  W.     [Page  128.] 


The  case  last  reported  as  well  as  the  following,  both  terminat- 
ing fatally,  perfectly  illustrate  this  serious  condition. 

W.  P. ,  age  thirty-six,  was  admitted  to  the  German  Hospital  March  ] , 
1 896,  with  the  followiug  history  :  For  three  weeks  previous  he  had  been  com- 
plaining of  gastric  disturbance,  headache,  pain  in  his  right  side,  and  general 
malaise.  Temperature  was  irregular,  99°-101°  ;  tongue  was  coated  ;  there  was 
occasional  vomiting  and  constipation.  There  were  repeated  attacks  of  pain, 
located  in  the  right  iliac  fossa,  at  intervals  of  three  or  four  days,  dating  from 
the  beginning  of  his  sickness. 

At  the  time  of  admission  his  temperature  was  101|°.  He  had  slight  sweats, 
and  complained  of  pain  in  his  right  iliac  fossa.  Tenderness  was  marked,  but 
nothing  else  could  be  determined  by  palpation  on  account  of  the  rigidity  and 
great  thickness'  of  the  abdominal  walls. 

Operation. — A  large  abscess  was  found  behind  the  csecum.     The  appendix 
pointed  N. ,  and  was  so  fragile  that  it  was  picked  out  in  shreds  from  the  lake 
of  pus  that  contained  it.     The  abscess-cavity  was  gently  irrigated  and  a  glass 
9 


130  APPENDICITIS. 

drainage  tube  inserted  to  the  site  of  the  appendix,  around  which  was  packed 
iodoform  gauze,  and  the  abdominal  incision  closed. 

For  four  days  the  patient  did  well,  the  temperature  and  pulse  were  normal, 
and  the  stomach  retentive.  On  the  fifth  day  he  had  sudden,  sharp  pain,  ab- 
dominal distention,  vomiting  which  became  persistent,  and  died  in  a  few  hours. 

Post-Mortem. — Purulent  peritonitis  ;  caecum  perforated  on  the  posterior 
wall.  The  opening  corresponding  to  the  site  of  the  appendix  was  large  enough 
to  admit  the  end  of  the  thumb. 


Most  of  these  conditions  are  liable  to  result  in  a  fsecal  fistula. 
I  consider  that  the  danger  of  leaving  a  diseased  appendix  in  the 
abdominal  cavity  is  greater  than  the  damage  likely  to  accrue 
from  rupturing  the  partition  wall  in  an  attempt  to  remove 
it.  I  believe  it  is  possible,  and  always  advisable,  to  remove  the 
organ  and  thus  make  the  operation  complete,  as  in  no  other 
way  will  recovery  be  assured,  though  I  must  emphasize  the 
fact  that  this  practice  is  only  justifiable  in  skilled  hands. 
For  the  occasional  operator  it  is  far  safer  that  he  content  him- 
self with  a  simple  evacuation  of  the  abscess.  To  leave  within 
the  abdomen  an  appendix  which  has  sloughed  ofi^,  or  which 
has  a  perforation  in  it,  or  which  has  been  intensely  inflamed 
by  migration  of  micro-organisms  through  its  walls,  I  believe 
to  be  incomplete  surgery.  An  appendix  which  is  deeply 
imbedded  in  a  wall  of  lymph,  whether  it  form  a  portion  of 
the  abscess  wall  or  not,  can  be  removed.  The  proper  dispo- 
sition of  gauze  and  careful  attention  to  technique  will,  in 
experienced  hands,  render  the  dangers  which  attend  the  re- 
moval of  the  appendix  much  less  than  those  which  will 
threaten  if  it  be  allowed  to  remain.  A  practice  which,  I 
believe,  is  a  frequent  one,  is  to  evacuate  the  abscess-cavity 
and,  after  affording  drainage,  to  close  the  wound  partially, 
without  any  effort  to  remove  the  appendix  unless  it  happen 
to  lie  in  plain  sight.  If  the  surgeon  has  a  perfect  knowledge 
of  the  anatomy  of  the  right  iliac  fossa  in  the  normal  condition, 
and  has  seen  enough  cases  to  familiarize  him  with  the  con- 


Plate  XVIII 


fWWWsir] 


The   Location   of  the  Simple   Incision 


Fig.    I 


Plate  xix 


Superficial  fascia 


Apor\eurosis  of  Ext,  Oblique 


Fig.   2 


Apoqeurosis  of  Ext.  Oblique 


Aponeurosis  of  Int.  Oblique 


Aporieurosis  of  Ext,  Oblique 


Sheath  of  Rectus 


TREATMENT.  131 

ditions  generally  found  after  disease,  I  fail  to  see  why  the 
organ  cannot  be  found,  as  is  claimed  by  some  operators, 
though  I  grant  that  sometimes  search  is  tedious  and  attended 
by  difficulty. 

Although  I  am  a  strong  advocate  of  the  removal  of  the 
appendix  in  almost  every  case  of  appendicitis,  yet  there  are 
a  few  conditions  in  which  I  prefer  to  defer  operation.  Per- 
sistent vomiting,  a  leaky  skin,  a  rapid  pulse  in  the  presence 
of  a  diffuse  peritonitis,  and  approaching  collapse,  in  my  judg- 
ment forbid  operation. 

I  have  frequently  been  asked,  when  refusing  to  operate  in 
such  cases,  why  we  should  not  give  the  patient  his  only 
chance.  It  is  my  belief  that  operation  at  this  time  is  in- 
variably attended  by  fatal  results. 

In  these  cases,  ice  to  the  abdomen,  calomel  given  to  the 
extent  of  moving  the  bowels  freely,  a  small  fly  blister  applied 
immediately  beneath  the  ensiform  cartilage,  nutritious  enemata, 
stimulants,  as  whiskey,  dry  champagne,  hypodermics  of  strych- 
nine, promise  more  than  radical  treatment.  When  by  such 
means  the  general  peritonitis  subsides  and  the  constitutional 
condition  warrants  it,  operation  may  be  done  with  the  hope  of 
a  successful  issue. 

Though  the  technique  of  the  operation  for  appendicitis  varies 
with  the  nature  of  the  case  and  the  conditions  present  at  the 
time  of  operation,  there  are,  nevertheless,  certain  features,  com- 
mon to  all,  which  should  be  carried  out  when  feasible. 

If  the  patient  has  chronic  appendicitis,  he  should  be  con- 
fined to  bed  for  from  one  to  two  days  before  the  time  set  for 
operation.  The  diet  should  be  light  and  easily  digested,  in 
order  to  leave  a  minimum  of  residue.  The  urine  must  be 
carefully  examined,  at  least  once,  and  oftener  if  time  permits. 
This  measure  should  never  be  neglected.  The  day  preceding 
operation  the  bowels   should  be   thoroughly  evacuated   by  a 


132  APPENDICITIS. 

laxative   and   on   the   morning   of  the   operation   an    enema 
given. 

The  patient  is  to  be  prepared  for  operation  as  follows: 
A  general  bath  of  hot  water  and  soap,  rinsing  off  with  a 
saturated  solution  of  boracic  acid.  An  entire  change  of 
clothes,  including  bed  linen.  The  immediate  site  of  the  opera- 
tion is  now  to  be  scrubbed  with  thymol  or  green  soap,  hot 
water,  and  a  soft  brush,  particular  care  being  paid  to  the 
umbilicus.  The  immediate  site  and  surrounding  skin  are  to  be 
shaved,  so  that  hair,  dead  epidermis,  and  dirt  may  be  removed. 
The  abdomen  should  now  be  rescrubbed  with  soap  and  water. 
This  is  followed  by  the  successive  application  of  ether  and 
alcohol  upon  a  wad  of  aseptic  cotton  in  order  to  remove  any 
fatty  material.  Lastly,  a  thorough  scrubbing  with  corrosive 
sublimate  of  the  strength  of  1  :  1000.  A  sterile  towel  or  a 
large  piece  of  gauze  moistened  with  the  sublimate  solution  is 
next  to  be  placed  upon  the  abdomen  and  retained  by  a 
bandage.  The  patient  is  then  ready  to  be  placed  upon  the 
table  on  the  following  day.  After  etherization  and  the  arrang- 
ing of  sterile  sheets  and  towels,  the  abdomen  should  be  again 
washed  in  1  :  2000  bichloride  solution.  We  are  now  prepared 
to  go  on  with  the  operation. 

Of  course,  it  is  not  always  possible  to  carry  out  this  detailed 
preparation  in  all  cases,  as  it  not  infrequently  happens  that 
the  operation  has  to  be  done  at  once  or  under  unfavorable 
circumstances. 

Incisions. — The  two  incisions  most  suitable  for  the  operation 
of  appendicitis  are  those  which  go  through  the  abdominal 
walls  to  the  right  of  the  median  line.  They  are  the  simple 
and  the  McBurney  incisions.  The  median  incision  for  appen- 
dicitis operations  is  not  anatomical,  is  irrational  and  danger- 
ous, particularly  if  pus  complicates  the  case. 

The  simple  incision  divides  the   layers  of  the   abdominal 


Plate  XX 


Sheath  of  Rectus 


Rectus  nr\ 


i/     if  \ Sheath  of  Rectus 

\l     'J 


Fiq,    2 


a,  b — Epigastric  veiqs  beneath 
Transversalis  fascia 


Rectus  iTi 


I Traqsversalis  fascia 


TREATMENT.  133 

wall  in  the  same  longitudinal  line,  displacing  the  outer  edge 
of  the  right  rectus  abdominalis  inward,  and  is  made  a  little  to 
the  inner  side  of  the  right  semilunar  line.  The  incision  down 
to  the  peritoneum  should  be  about  three  inches  long,  and 
begins  one  inch  above  a  line  drawn  between  the  anterior 
superior  iliac  spine  and  the  umbilicus ;  the  incision  intersects 
this  line  at  a  distance  varying  from  one-half  to  one  inch  to 
the  umbilical  side  of  its  centre.     (See  Plate  XVIII.) 

In  pus  cases  where  the  collection  is  circumscribed  it  is  often 
advisable  to  make  the  incision  well  to  the  right,  running 
parallel  and  just  above  Poupart's  ligament.  This  incision 
permits  of  better  drainage  and  greatly  decreases  the  danger  of 
breaking  through  the  inner  wall  of  the  abscess  cavity  in  the 
manipulations  necessary  for  the  removal  of  the  appendix. 

The  incision  in  the  peritoneum  should  at  first  be  one  inch 
in  length,  simply  large  enough  for  the  insertion  of  the  index 
finger.  Through  this  incision  the  csecum  can  be  picked  up 
and  brought  out,  and  with  it  the  appendix.  If  the  caecum  or 
appendix  be  bound  down,  or  if  pus  be  present,  it  will  be  wise 
to  enlarge  the  peritoneal  incision.  Bleeding  should  be  con- 
trolled with  hsemostats  before  the  peritoneum  is  opened.  The 
steps  in  this  operation  are  illustrated  in  Plates  XIX  to  XXIV 
inclusive. 

McBurney  has  suggested  a  method  of  opening  the  abdomen, 
which,  while  more  difficult  of  execution  than  the  simple 
incision,  is  far  less  liable  to  be  followed  by  ventral  hernia.  It 
is  only  applicable  to  those  cases  uncomplicated  by  pus. 

The  skin  incision  in  this,  the  McBurney  operation,  is 
slightly  curved,  with  the  convexity  outward.  It  is  about  two 
inches  long  and  is  midway  between  the  right  semi-lunar  line 
and  the  anterior  superior  spine  of  the  ilium.  (See  Plate 
XXV.)  The  section  of  the  external  oblique  muscle  and 
aponeurosis   should   correspond,   great    care   being   taken   to 


134  APPENDICITIS. 

separate   these  tissues  in  the  same  line,  and  not  to  cut  any 
fibres.     This  is  easily  accomplished. 

When  the  edges  of  the  wound  in  the  external  oblique  are 
now  strongly  pulled  apart  by  retractors,  a  considerable  expanse 
of  the  internal  oblique  muscle  is  seen,  the  fibres  of  which  cross 
the  opening  formed  somewhat  obliquely.  Next  divide  the 
delicate  fascia  covering  the  internal  oblique  in  the  direction 
of  its  fibres.  With  a  blunt  instrument,  such  as  the  handle  of 
a  knife  or  the  point  of  closed  scissors,  the  fibres  of  the  internal 
oblique  and  transversalis  muscles  can  now  be  separated  in  a 
line  parallel  with  their  course,  without  cutting  more  than  an 
occasional  fibre.  Blunt  retractors  should  now  be  introduced 
into  this  incision  in  turn  and  the  edges  separated. 

The  transversalis  fascia  is  now  well  exposed  and  divided  in 
the  same  line,  separating  with  it  the  preperitoneal  fat.  Last  of 
all  a  transverse  section  of  the  peritoneum  is  made. 

Two  sets  of  retractors  must  at  times  be  in  use,  one  holding 
open  the  superficial  wound  from  side  to  side,  the  other  separat- 
ing the  edges  of  the  deeper  wound  from  above  downward ; 
ordinarily,  however,  I  find  one  set  of  small  retractors  sufficient. 
A  considerable  opening  is  thus  formed,  through  which,  in 
suitable  cases,  the  caput  coli  can  be  easily  handled  and  the 
appendix  removed. 

The  appendix  having  been  amputated  and  the  stump 
buried,  the  transverse  wound  in  the  peritoneum  is  then  closed 
by  continuous  catgut  suture.  The  parallel  wound  in  the 
fascia  transversalis  is  sutured  in  the  same  way.  The  fibres  of 
the  internal  oblique  and  transversalis  muscles  fall  together 
as  soon  as  the  retractors  are  withdrawn,  but  with  a  couple 
of  fine  catgut  stitches  tiie  closure  can  be  made  more  com- 
plete. The  wound  in  the  external  oblique  aponeurosis  is 
closed  with  a  continuous  catgut  suture.  The  skin  and  super- 
ficial  fascia   are    now  closely  united   by   a   continuous,   sub- 


Plate  XXI 


Fig. 


Pre-peritoqeal  fat 


Epigastric  veir\s 


Fig.  2 


Peritoneum 


TREATMENT.  135 

cuticular  suture  and  the  wound  hermetically  sealed  by  iodoform 
collodion. 

When  the  operation  is  completed  it  will  be  seen  that  the 
gridiron-like  arrangement  of  the  muscular  and  tendinous 
fibres,  to  which  the  abdominal  wall  largely  owes  its  strength,  is 
almost  as  completely  restored  as  if  no  operation  had  been  done. 

Plates  XXVI  to  XXXI  inclusive  show  the  various  steps  of 
the  operation  done  by  this  method. 

In  performing  this  operation  I  have  noticed  several  ad- 
vantages. 

In  the  first  place,  muscular  and  tendinous  fibres  are  separated, 
but  not  divided,  so  that  muscular  action  cannot  tend  to  draw 
the  edges  of  the  wound  apart,  but,  on  the  other  hand,  actively 
approximates  them.  Except  during  the  incision  of  the  skin, 
almost  no  bleeding  occurs.  The  fascia  transversalis,  not  being 
drawn  away  by  the  retraction  of  the  deepest  layer  of  muscular 
fibres,  is  easily  sutured,  and  thus  greater  strength  of  repair  is 
assured.  No  muscular  fibres  or  large  nerves  having  been 
divided,  pain  after  operation  is  almost  absent.  The  ilio- 
hypogastric is  the  only  nerve  encountered  and  should  be  pushed 
aside.  The  operation  requires  rather  more  time  than  the 
simple  one.  The  opening  into  the  peritoneal  cavity  is  not 
large,  but  may  be  made  larger,  if  necessary,  by  continuing  the 
separation  of  the  fibres  of  the  internal  oblique  and  trans- 
versalis, and  dividing  the  conjoined  aponeurosis  in  the  same 
line  with  scissors.  In  the  opposite  direction  the  separation  of 
muscular  fibres  may,  upon  necessity,  be  carried  as  far  as  the 
crest  of  the  ilium,  or  the  conjoined  aponeurosis  may  be  divided 
vertically. 

In  both  operations  it  will  sometimes  be  necessary  to  enlarge 
the  incision  after  the  peritoneum  has  been  opened.  When 
adhesions  are  strong  and  numerous,  tying  down  the  csecum  and 
appendix,  it  is  wiser  to  have  plenty  of  room  in  which  to  work. 


136  APPENDICITIS. 

This  also  is  true  when  pus  is  present,  and  when,  from  the 
appearance  of  the  right  iliac  fossa,  secondary  collections  are 
suspected. 

As  soon  as  the  peritoneum  is  opened,  the  csecum  should  be 
delivered  and  with  it  the  appendix.  After  the  appendix  is  in 
the  grasp  of  the  thumb  and  finger  the  csecum  should  be 
replaced  in  the  abdominal  cavity. 

The  meso-appendix  is  now  to  be  tied  off  and  cut  away  from 
its  appendiceal  attachment.  This  is  accomplished  by  trans- 
fixing its  base  by  a  small  pair  of  forceps.  A  piece  of  catgut  is 
engaged  in  the  jaws  of  the  forceps,  which  are  then  withdrawn 
and  with  them  one-half  of  the  catgut  ligature.  After  tying  the 
ligature,  the  meso-appendix  is  cut  away  with  a  pair  of  scissors. 

A  circular  incision  is  now  made  through  the  serous  eoat  of 
the  appendix  one  quarter  of  an  inch  from  its  junction  with  the 
c£ecum.  The  serous  coat  is  next  stripped  back  toward  the 
csecum,  leaving  a  cuff  of  peritoneum,  after  which  the  appendix 
is  ligated  with  silk  and  the  organ  removed.  The  mucous 
membrane  of  the  stump  of  the  organ  is  curetted  and  anti- 
septicized  with  a  solution  of  mercury  bichloride  and  carbolic 
acid  (1  :  4000  and  1  :  60  respectively).  The  serous  coat  is 
stitched  with  a  fine  needle  and  silk  over  the  stump  thus 
left.  The  stump  now  covered  with  peritoneum  is  invag- 
inated  into  the  wall  of  the  csecum  with  continuous  Lem- 
bert  sutures.  By  this  method  of  disposing  of  the  stump,  fsecal 
fistula  is  impossible,  and  therefore  it  is  a  method  which  should 
be  carried  out  whenever  circumstances  permit.  When  the  ap- 
pendix is  gangrenous  or  friable,  or  is  much  involved  in  inflam- 
matory lymph,  we  often  have  to  content  ourselves  with  a 
simple  ligature  taking  in  all  the  coats  of  the  organ.  The 
stump  thus  remaining  should,  if  possible,  be  invaginated  into 
tlie  csecum. 

Very  often,  in  cases  where  pus  complicates  the  operation,  there 


Fig, 


Plate  xxil 


Great  omentum 


Fig.  2 


Caecum. 


Base  of  appendix 


Fig. 


Plate  XXlll 


Gauze 


Gauz 


Gauze  distributed  around  bov^el,  serous  coat  turned  back  ar^d  appendix  tied  off 

Fig.  2 


Gauze 


Gauze 


Serous  coat  of  appendix  sutured  over  stump 


TREATMENT.  137 

is  no  confining  wall  of  lymph,  or  if  present  it  is  incomplete  or 
so  delicate  that  the  appendix  cannot  be  removed  without 
endangering  the  general  peritoneal  cavity.  It  is,  therefore,  a 
matter  of  the  first  importance  that  some  method  be  instituted 
by  which  the  spread  of  infection  will  be  rendered  impossible 
during  the  necessary  manipulation  for  the  removal  of  the 
organ.  This  is  conveniently  and  thoroughly  accomplished  by 
the  proper  disposition  of  sterilized  gauze.  Pieces  about  six 
inches  in  length  by  four  inches  in  width  will  be  found  most 
useful. 

Since  the  success  in  the  operative  treatment  of  appendicitis 
complicated  by  pus  formation  will  largely  depend  upon  a 
knowledge  of  the  anatomical  varieties  of  this  form  of  abscess, 
as  well  as  upon  a  complete  understanding  of  the  safest  method 
of  evacuating  the  pus  and  removing  the  appendix  without 
peritoneal  infection,  a  brief  description  with  the  operative 
technique  is  here  given. 

Depending  upon  the  location  of  the  pus,  appendiceal  abscess 
is  met  with  as  one  of  four  varieties :  First,  and  the  most  com- 
mon in  my  experience,  is  the  collection  located  post-csecal,  or 
between  the  layers  of  the  ascending  meso-colon ;  second,  the 
collection  is  immediately  beneath  the  anterior  parietal  peri- 
toneum, being  confined  by  the  ceecum,  coils  of  small  intestine, 
the  omentum,  the  appendix,  the  parietal  peritoneum,  and 
masses  of  lymph ;  third,  the  collection  is  located  in  the  pelvis, 
which  is  usually  entirely  shut  off  from  the  general  peritoneal 
cavity ;  fourth,  pus  is  free  in  the  general  peritoneal  cavity. 

In  dealing  with  the  first  variety,  as  soon  as  the  peritoneal 
cavity  is  opened  the  first  thing  to  be  done  is  to  protect  the  gen- 
eral peritoneum  bj^  the  proper  disposition  of  gauze,  as  has  been 
described.  The  next  step  is  to  open  the  collection  by  breaking 
through  either  the  outer  layer  of  the  ascending  meso-colon  or 
through  the  layer  of  lymph,  attaching  the  outer  wall  of  the 


138  APPENDICITIS. 

c?ecum  to  the  floor  or  the  side  of  the  iliac  fossa,  as  the  case 
may  be.  Turn  the  patient  well  over  upon  the  right  side  and 
irrigate  the  cavity  until  the  water  returns  clear.  The  cavity  is 
now  to  be  wiped  out  first  with  dry  iodoform  gauze,  then  with 
gauze  wet  with  a  solution  of  bichloride  and  carbolic  acid.  After 
drying  the  cavity  with  iodoform  gauze  the  appendix  is  located 
and  removed.  After  the  removal  of  the  appendix,  and,  when 
possible,  the  invagination  of  the  stump,  the  cavity  is  to  be 
lightly  packed  with  narrow  strips  of  iodoform  gauze  and  the 
abdominal  wall  sutures  introduced  but  left  untied.  The  pieces 
of  gauze  used  in  walling  off  the  general  peritoneal  cavity  are 
now  removed  carefully  and  the  wound  aseptically  dressed. 
After  forty-eight  or  seventy-two  hours  the  gauze  packing  is 
removed,  first  saturating  it  with  sterilized  salt  or  boracic  acid 
solution;  the  sutures  are  tied  and  the  wound  dressed.  It  is 
not  always  possible  to  completely  close  the  wound  after  the 
removal  of  the  packing,  but  this  must  depend  upon  the  condi- 
tion of  the  wound.  If  there  is  escape  of  pus  following  the 
removal  of  the  gauze,  it  will  be  necessary  to  allow  the  central 
portion  of  the  wound  to  heal  by  granulation.  It  is  in  this 
variety  of  abscess,  i.  e.,  with  the  collection  post-csecal,  that  the 
greatest  difficulty  is  encountered  in  the  removal  of  the 
appendix. 

The  evacuation  of  the  collection  located  behind  the  caecum  and 
colon  must  of  necessity  entail  opening  the  general  or  larger  of 
the  two  peritoneal  cavities  unless  an  incision  is  made  through 
the  loin,  as  in  opening  a  nephritic  or  peri-nephritic  abscess. 
This  method  would  suffice  were  the  exact  location  of  the  collec- 
tion known  definitely  beforehand  and  if  the  operator's  inten- 
tion was  simply  to  evacuate  the  abscess  and  not  to  attempt 
to  remove  the  appendix.  The  operator  who  believes  it  bad 
practice  to  take  out  the  appendix  in  pus  cases  unless  it  appear 
right  under  his  eye  and  finger,  after  having  opened  from  in 


Gauze 


F,g.    I 


PLATE   XXIV 


Stump  of  appendix  invaginated 
Fig.    2 


Gauze 


Gauze 


Caecum  replaced  and  gauze  laid  beneath  peritoneal  opening 


TREATMENT.  139 

front  and  determining  that  the  collection  is  in  this  situation, 
can  accommodate  himself  by  closing  the  anterior  incision  and 
then  proceed  to  do  the  loin  operation.  It  is  unnecessary  to  say, 
however,  that  this  would  subject  the  patient  to  an  incomplete 
operation. 

In  the  second  variety,  immediately  upon  carrying  the  in- 
cision through  the  parietal  peritoneum,  the  collection  is  opened. 
The  pus  cavity  is  evacuated  and  antisepticized  without  irri- 
gating. Irrigation  in  this  variety  is  dangerous  on  account  of 
the  delicacy  of  the  confining  wall,  rendering  dissemination  of 
infection  more  liable.  Evacuation  is  ordinarily  accomplished 
without  risk  of  infecting  the  peritoneum  since  the  incision 
which  corresponds  to  the  most  prominent  part  of  the  swelling, 
or  if  no  swelling  is  present,  to  the  point  over  the  involved 
region  most  sensitive  to  pressure,  comes  directly  down  upon  the 
collection.  This  variety  of  abscess  can  usually  be  said  to  be 
present  when  the  abdominal  muscles  along  the  line  of  the  in- 
cision are  found  to  be  oedematous  and  infiltrated.  If  the  mus- 
cles are  not  thus  affected  the  abnormality  will  be  found  in  the 
transversalis  fascia  and  pre-peritoneal  fat.  Unless  the  case  be 
of  several  days'  standing,  the  amount  of  pus  in  this  variety  is 
small  in  comparison  to  the  first  class,  and  is  therefore  readily 
disposed  of  by  mopping  with  pieces  of  iodoform  gauze.  After 
locating  the  appendix,  it  is  dissected  free  and  small  pieces  of 
gauze  inserted  as  it  is  loosened  from  its  bed,  so  that  when  the 
appendix  is  entirel}^  free,  its  original  site  will  be  occupied  by 
the  pieces  of  gauze  which  were  introduced  during  the  dissec- 
tion. It  can  now  be  tied  off  and  removed,  and  the  cavity  and 
wound  treated  as  in  the  first  instance. 

In  this  second  variety  of  abscess  it  frequently  happens  that 
the  collection  is  not  completely  shut  off  at  its  lower  end,  but  is 
in  communication  with  the  pelvis  ;  therefore,  I  make  it  a  prac- 
tice to  pass  a  glass  drainage  tube  down  to  the  floor  of  the  pelvis 


140  APPENDICITIS. 

to  definitely  determine  its  condition.  I  have  on  many  occa- 
sions, when  operating  with  this  form  of  abscess  present, 
evacuated  but  a  drachm  or  two  of  pus  upon  cutting  through 
the  peritoneum.  Upon  passing  a  glass  drainage  tube  into  the 
pelvis  as  much  as  half  a  pint  of  pus  has  escaped. 

In  the  third  variety,  the  peritoneal  cavity  being  opened  it 
should  be  walled  off  down  to  the  roof  of  the  pelvis.  The  finger 
is  then  carried  over  the  brim  of  the  true  pelvis  down  to  the 
collection,  and  a  glass  drainage  tube  introduced  with  the  finger 
as  a  guide.  Irrigation  is  carried  out  through  the  glass  tube. 
The  appendix  is  now  located  and  removed.  After  the  removal 
of  the  organ  the  glass  drainage  is  reinserted  and  left  in  place 
for  from  one  to  four  days,  depending  upon  circumstances.  The 
gauze  packing  is  to  be  removed  and  replaced  by  a  small  piece 
which  is  allowed  to  remain  until  adhesions  have  formed  which 
will  close  off  the  cavity,  usually  in  twenty-four  or  forty-eight 
hours.  The  upper  portion  of  the  wound  is  to  be  closed  and 
only  the  lower  portion,  through  which  the  glass  tube  and  the 
end  of  the  gauze  packing  protrudes,  is  allowed  to  remain 
open. 

The  evacuation  of  the  collection  through  either  the  rectum 
or  the  vagina  in  the  third  variety  of  abscess,  i.  e.,  pelvic,  I  re- 
gard as  unsurgical  and  attended  by  more  risk  than  incision 
through  the  abdominal  walls.  By  the  latter  means  it  is 
definitely  known  what  is  being  done,  nothing  being  taken  for 
granted. 

In  operating  through  the  belly  walls,  the  appendix  can  be 
removed  at  the  time  of  evacuation  of  the  abscess,  a  procedure 
which,  in  my  judgment,  is  so  important.  Operation  in  these 
cases  of  pelvic  collections  has,  in  my  hands,  been  among  the 
most  successful  of  all  the  cases  of  acute  appendicitis  attended 
Vjy  pus  formation. 

In  the  fourth  variety,  the  general  peritoneal  cavity  is  to  be 


Plate  XXV 


^ 


V 


The   Location   of  the   McBurney   Incision 


Fig.    I 


Plate  xxvi 


Skiq 


Aponeurosis  of  Ext.  Oblique 


Superficial  fascia 


Fig.   2 


Delicate  fascia  covering  int.  oJDlique  m, 


TREATMENT.  141 

thoroughly  irrigated,  appendix  removed,  glass  drainage  intro- 
duced into  the  pelvis,  and  wound  closed. 

If  the  case  is  of  long  enough  standing  to  have  allowed  ex- 
tensive adhesions  to  form  throughout  the  peritoneal  cavity,  it 
may  be  necessary  to  provide  capillary  drainage  by  means  of 
strips  of  gauze  distributed  in  various  directions,  because  irriga- 
tion will  not  reach  all  the  nooks  and  crannies  of  the  peritoneal 
cavity  when  extensive  adhesions  have  formed. 

The  fourth  variety  is  met  with  in  the  very  rapidly  develop- 
ing cases  of  appendicitis  which  call  for  immediate  operative 
interference,  and  I  have  met  with  this  condition  within  twelve 
hours  after  the  onset  of  an  acute  attack,  as  the  following  case 
will  illustrate : — 

Annie  B. ,  colored,  age  forty-two,  was  suddenly  seized  on  the  morning  of 
June  15,  1895,  with  acute  abdominal  pain  accompanied  by  nausea  and  vomit- 
ing. She  attempted  to  cook  breakfast  but  was  compelled  to  go  to  bed.  Not- 
withstanding the  use  of  home  remedies  and  two  large  doses  of  castor-oil, 
which  had  moved  her  bowels  very  freely,  she  suifered  excruciating  pain. 

Immediately  after  seeing  her  I  advised  operation,  to  which  she  gladly  con- 
sented. I  sent  her  to  the  German  Hospital  and  operated  the  same  evening. 
Found  the  abdominal  cavity  full  of  pus ;  a  very  much  enlarged  and  acutely 
inflamed  appendix  which  was  covered  with  strips  of  inflammatory  exudate. 
Removed  appendix  ;  washed  out  abdominal  cavity  with  sahne  solution,  and 
introduced  glass  drainage  into  pelvis. 

Recovery  speedy  and  uninterrupted.  Returned  to  the  house  in  three  weeks, 
and  resumed  her  duties  as  cook  at  the  end  of  the  fourth  week. 

There  usually  should  be  little  or  no  difficulty  in  finding  and 
removing  the  appendix  in  the  fourth  variety  of  abscess,  as  the 
anatomic  landmarks  are  but  slightly,  if  at  all,  impaired  or 
distorted  by  the  inflammatory  process. 

In  the  first  three  varieties  it  requires  skilful  manipulation 
to  find  and  remove  the  appendix  without  infecting  the  general 
peritoneal  cavity.  In  the  first  and  third  varieties,  i.  e.,  the  post- 
csecal  and  pelvic  collections,  equally  great  care  must  be  exer- 
cised to  avoid  infecting  the  peritoneum  during  the  simple  pus 
evacuation. 


142  APPENDICITIS. 

In  cases  where  there  has  been  no  attempt  upon  the  part  of 
nature  to  wall  off,  or  where  there  are  no  adhesions  between  the 
anterior  layer  of  peritoneum,  the  omentum,  and  the  underlying- 
bowel,  it  will  be  necessary  to  place  a  series  of  pieces  of  gauze 
in  different  directions  so  that  they  will  drain  the  general 
peritoneal  cavity.  This  is  accomplished  by  packing  each  piece 
in  endwise  and  allowing  the  outer  end  to  protrude  from  the 
wound.  In  closing  the  wound  the  stitches  between  which  the 
ends  of  the  gauze  project  are  to  be  left  long,  so  that  they  can 
be  tied  after  the  removal  of  the  gauze. 

Frequently  after  the  completion  of  a  toilet  of  an  abscess 
cavity  in  the  right  iliac  fossa,  and  particularly  in  that  class  of 
cases  where  immediately  upon  opening  the  peritoneum  pus 
escapes,  the  general  peritoneal  cavity  not  having  been  com- 
pletely shut  off,  a  glass  drainage  tube  carried  down  into  the 
bottom  of  the  pelvis  will  bring  to  light  a  hitherto  unsuspected 
collection  of  pus. 

In  closing  the  abdominal  wound  one  of  several  methods 
may  be  used :  1.  Interrupted  sutures  including  all  the  layers. 
2.  Buried  sutures  uniting  the  different  layers  separately. 

However,  the  plan  of  procedure  which  I  most  often  carry  out 
in  closing  the  abdominal  wound  in  the  simple  incision,  and 
which  I  believe  to  be  the  strongest  safeguard  against  hernia,  is 
that  of  buried  sutures,  the  peritoneum  and  skin  being  stitched 
separately  with  continuous  cat-gut  suture  and  the  muscles  and 
fascia  by  mattress  suture  or  simple  uninterrupted  suture  of 
kangaroo  tendon,  silver  wire,  or  worm-gut.  The  materials 
used  in  closing  the  incision  are  silk,  silk-worm  gut,  kangaroo 
tendon,  and  silver  wire.  The  last  is  most  readily  rendered 
aseptic  and  is  the  only  one  about  the  asepsis  of  which  we 
can  be  absolutely  positive.  Where,  on  account  of  drainage, 
it  is  not  possible  to  close  the  entire  wound,  place  as  many 
buried  sutures  as  will  close  the  wound  to  the  point  of  exit 


Fig.    I 


Plate  xxvil 


Int.  oblique  m. 


Fig.   2 


Fibres  of  internal  oblique  and  transversalis  separated  shiowing 
Transversal  is  fascia,   a 


Fig.  I 


Plate  XXVII 


Traqsversalis  fascia 


"-  Peritoneum 


Fig.  2 


X  ^Peritoneum 


Great  omentumi 


Traqsversalis  fascia 


TREATMENT.  143 

of  the  drain,  where  two  or  more  simple  or  buried  sutures  of 
silk-worm  gut  are  placed.  These  two  sutures  are  allowed  to 
remain  long  and  untied,  so  that  the  edges  of  the  incision 
corresponding  to  the  drain  can  be  drawn  together  after  the 
removal  of  the  gauze  or  tube. 

In  closing  by  buried  sutures,  it  will  not  be  necessary  in  all 
cases  to  stitch  the  peritoneum,  as  sometimes  its  cut  edges  come 
evenly  together  when  the  edges  of  the  wound  are  approximated. 
If,  however,  they  do  not  approximate  well,  it  will  be  necessary 
to  stitch  them  together  first  with  a  continuous  cat-gut  suture. 

The  next  layer  consists  of  mattress  sutures  or  simple 
interrupted  sutures  of  kangaroo  tendon,  which,  on  account  of 
its  great  strength,  its  durability  against  absorption,  and  com- 
paratively easy  aseptization,  is  an  excellent  suture  material. 
The  needle  best  adapted  for  this  suture  is  a  French  instrument 
(Reveridan's)  with  the  eye  in  the  point,  which  can  be  opened 
and  closed  by  a  thumb  service  arrangement  in  the  handle. 
A  curved  Hagedorn  needle  with  a  holder  will  answer  the 
purpose,  but  is  less  convenient. 

To  introduce  the  mattress  suture  we  begin  on  the  outer  side 
of  the  wound.  The  needle  is  thrust  through  the  aponeurosis 
of  the  external  oblique  and  through  the  internal  oblique  and 
transversalis  muscles  about  one-half  inch  to  the  outer  side  of 
the  incision.  It  next  traverses  the  transversalis  fascia,  con- 
tinuing out  into  the  wound  between  the  pre-peritoneal  fat  and 
the  peritoneum,  which  last  is  not  usually  included  in  the  stitch. 
After  carrying  the  needle  across  the  incision,  it  is  thrust 
through  the  pre-peritoneal  fat  of  the  side  opposite  its  point  of 
introduction  one-half  inch  from  the  inner  edge  of  the  incision. 
It  now  pierces  the  transversalis  fascia,  the  rectus  muscle,  and  its 
posterior  and  anterior  sheath.  A  strand  of  kangaroo  tendon 
is  threaded  into  the  eye  of  the  needle,  and  by  holding  one  end 
of  the  suture  and  withdrawing  the  needle,  the  needle  end  of  the 


144  APPENDICITIS. 

tendon  will  be  drawn  through  and  the  first  part  of  the  stitch 
will  be  in  place.  Disengaging  the  needle,  we  again  thrust  it 
through  the  tissues  in  the  order  above  described,  beginning 
one-half  inch  from  the  outer  edge  of  the  incision  and  one- 
quarter  inch  above  the  first  point  of  introduction  of  the  needle. 
When,  following  the  course  above  described,  the  eye  of  the 
needle  has  penetrated  the  anterior  layerl  of  the  sheath  of  the 
rectus,  we  thread  one  end  of  the  suture  which  is  already  in 
place  and  withdraw  the  instrument,  carrying  with  it  the  tendon. 
Now  both  of  the  ends  are  through  the  aponeurosis  of  the  exter- 
nal oblique  muscle  to  the  same  side  of  the  incision,  but  one- 
quarter  inch  apart,  thus  giving  us  a  U-shaped  suture  with  two 
free  ends.  When  these  ends  are  tightly  tied  together  we  secure 
a  firm  suture,  which  brings  together  and  retains  those  tissues, 
both  muscular  and  fascial,  which  when  united  form  a  barrier 
to  ventral  hernise.  The  only  objection  which  can  be  raised 
against  this  method  is  the  formation  of  a  ridge  along  the  line 
of  opposition  of  the  tissue  included  in  the  buried  sutures.  By 
using  the  simple  interrupted  buried  suture  this  bunching  of 
the  tissue  is  overcome  and  the  edges  of  the  wound  exactly 
proximated.  I  therefore  prefer  the  latter  method.  In  Fig.  3 
the  result  with  the  mattress  suture  is  shown  ;  in  Fig.  4  that 
with  the  simple  suture.  The  skin  wound  is  closed  by  a 
continuous,  sub-cuticular  suture  as  follows : — 

Starting  at  the  lower  end  of  the  incision,  the  needle  is  thrust 
horizontally  in  and  out  through  the  dermis  of  first  one  side, 
then  the  other,  for  distances  of  one-quarter  inch  until  the  skin 
edges  are  approximated  throughout.  The  suture  is  fastened 
in  the  upper  end  of  the  wound.  Silver  wire  is  preferred  by 
some  surgeons  for  the  continuous  subcutaneous  stitch,  because 
it  is  not  absorbable  and  therefore  keeps  the  edges  of  the  wound 
in  apposition  until  perfectl}^  healed,  after  which  it  can  be  with- 
drawn. 


Fig. 


PLATE  XXIX 


Caecum 


Appendix  and 
nqeso-appendix 


Fig,   2 


Gauze 


Gauze 


TREATMENT. 


145 


The  dressing  for  these  cases  consists  of  a  layer  of  iodoform 
collodion  and  a  strip  of  iodoform  gauze,  over  which  is  painted 
a  second  layer  of  the  iodoform  collodion.  The  dressing  is 
completed  by  placing  a  pad  of  sterilized  gauze  over  the  wound, 
retaining  it  in  place  by  strips  of  adhesive  plaster.  The  latter 
part  of  the  dressing  is  to  guard  against  sudden  tension  on  the 
wound  from  muscular  action  due  to  coughing,  straining,  etc. 

If  in  closing  the  wound  when  the  simple  incision  has  been 
used,  the  method  of  interrupted  sutures  including  all  the  layers 


Fie.  3. 


Jk= 


5fe 


^- 


Fig.  4. 


is  followed,  a  long,  straight  needle,  not  too  large  in  diameter, 
should  be  employed.  The  needle  is  thrust  through  the  skin 
about  one-fourth  of  an  inch  from  the  edge  of  the  incision,  pierces 
all  the  layers,  running  obliquely  backward  so  that  the  opening 
it  makes  in  the  peritoneum  will  be  about  one  inch  from  the 
edge  of  the  incision.  This  insures  contact  of  the  edges  of  the 
cut  peritoneum.  The  stitches  are  interrupted,  being  about  one- 
fourth  of  an  inch  apart.  Superficial  stitches  of  silk  can  be  used 
to  overcome  any  gaping  in  the  skin.  Before  the  stitches  for 
closing  the  wound  are  introduced,  a  piece  of  gauze  should  be 
spread  over  the  underlying  intestines  so  that  they  may  be  free 

10 


146  APPENDICITIS. 

from  danger  of  puncture.  Bleeding  which  may  occur  will  be 
absorbed  by  this  gauze,  which  is  to  be  removed  before  the 
stitches  are  tied. 

A  frequent  accident  in  closing  the  simple  incision  is  the 
puncture  of  one  of  the  deep  epigastric  veins.  I  know  of  one 
case  where  such  an  occurrence  caused  the  death  of  the  patient 
from  hemorrhage.  If  this  accident  occurs,  the  surgeon  is  not 
justified  in  closing  the  wound  until  the  vein  is  ligated. 

The  deep  epigastric  veins  can  be  exposed  by  lifting  up  and 
drawing  inward  the  rectus  muscle,  separating  it  from  the 
transversalis  fascia,  beneath  which  they  run.  By  remember- 
ing this  fact,  it  is  a  simple  matter  to  find  and  ligate  the  injured 
vein. 

Some  surgeons  prefer  the  straight,  round  needle,  as  they 
think  it  less  liable  to  puncture  these  vessels.  I  use  the 
straight,  spear-pointed  needle,  as  it  is  much  easier  to  mani- 
pulate and  I  believe  does  not  increase  the  danger  of  puncture. 

The  armamentarium  necessary  for  a  complete  appendiceal 
operation  is  as  follows : — 

Knife. 

One  pair  of  toothed  forceps. 

One  pair  of  dissecting  forceps. 

Probe. 

Six  haemostatic  forceps. 

One  pair  of  simple  retractors. 

Catgut. 

One  straight  needle,  one  long  curved  Hagedorn  needle,  or  a 
handled  needle  with  an  eye  in  the  point  (Reveridan's),  and 
twelve  strands  of  silk-worm  gut. 

Kangaroo  tendon. 

Silver  wire. 

Small  needle  and  fine  silk. 

Ten  yards  of  sterilized  gauze. 


Plate  XXX 


Fiq. 


Serous  coat  sutured  over  stump 


Fig.  2 


Sturqp  Invaginated 


Plate  XXXI 


Fig,   I 


Caecum 


Per 


qsversalis  fascia 


Great  omenturY\ 


Fig  2 


Traqsversalis  fascia 


Caecum 


Peritoneum 


TREATMENT,  147 

Two  yards  of  sterilized  iodoform  gauze. 
Sterilized  cotton,  adhesive  strips,  bandage,  rubber  dam. 
Corrosive  sublimate  and  carbolic  acid. 
Irrigating  apparatus — salt  solution ;  boric  acid  solution. 
Drainage  tubes,  rubber,  glass,  various  sizes. 
Glass  syringe. 

The  more  the  fingers  displace  instruments,  the  better  the 
results. 


COMPLICATIONS  AND   SEQUELAE. 

The  complications  of  appendicitis  may  be  divided  into  those 
which  are  encountered  at  the  time  of  removal  of  the  organ 
and  those  which  arise  during  the  course  of  the  disease  and 
interfere  with  the  prompt  recovery  of  the  patient  after  opera- 
tion. 

Complications  of  the  Operative  Treatment  of  Appendicitis. — The 
condition  of  the  abdominal  walls  may  offer  serious  difficulty 
in  removing  the  appendix.  If,  on  account  of  a  great  deposi- 
tion of  fat,  the  belly  walls  are  very  thick,  they  will  be  harder 
to  manage  and  increase  the  difficulty,  both  in  finding  the 
caecum  and  appendix  and  bringing  them  into  the  wound ;  this 
difficulty  can  be  overcome  only  by  enlarging  the  incision.  If 
the  caecum  and  appendix  are  tied  down  by  adhesions,  the 
difficulty  in  the  operation  will  be  correspondingly  increased. 

In  a  recent  operation  abdominal  walls  were  encountered 
over  two  inches  thick ;  the  csecum  and  appendix  were  firmly 
bound  to  the  floor  of  the  iliac  fossa  by  exudate  and  adhesions. 
The  appendix,  which  was  very  difficult  to  free  on  account  of 
the  thickness  of  the  abdominal  walls,  was  so  friable  that  it  was 
torn  off  in  the  endeavor  to  ligate  it.  The  stump,  moreover, 
could  not  be  brought  into  the  wound  on  account  of  the  firm 
adhesions  of  the  caecum.  A  ligature,  thrown  around  the 
stump,  below  a  pair  of  hsemostats,  was  then  tightly  tied,  and  the 
stump  invaginated  into  the  walls  of  the  c£ecum  and  covered 
by  stitching  the  coats  of  the  caecum  over  it  by  means  of  a 
short  curved  needle  in  a  needle  holder.  These  accidents  and 
technical  difficulties  were  largely  due  to  the  thickness  of  the 

148 


COMPLICATIONS    AND    SEQUEL^*:.  149 

belly  walls,  which  prevented  free  access  to  the  seat  of  the 
trouble. 

Much  inconvenience  and  delay,  moreover,  is  frequently 
caused  by  difficulties  in  effecting  proper  anaesthesia.  Patients 
are  often  seen  in  whom  it  is  almost  impossible  to  produce 
complete  muscular  relaxation;  in  such  cases  there  are  rigid 
abdominal  walls  with  the  bowels  bulging  out  of  the  wound 
at  most  inopportune  times.  A  few  drops  of  chloroform  added 
to  the  ether  will,  however,  generally  overcome  this  trouble. 

Unusual  positions  of  the  appendix  will  often  cause  the 
surgeon  difficulty.  I  have  frequently  met  with  cases  in  which 
the  organ  might  be  supposed  to  be  absent,  being  finally  found 
lying  against  the  posterior  wall  within  the  peritoneal  covering 
of  the  caecum,  the  one  layer  of  serous  membrane  being  reflected 
over  both. 

If,  under  these  circumstances,  a  pus  collection  surrounds  it, 
the  appendix  is  sometimes  exceedingly  difficult  to  find,  and  its 
removal  is  correspondingly  arduous.  Under  such  conditions  it 
is  advisable  to  cut  through  the  external  layer  of  the  meso-colon 
in  order  to  gain  free  access  to  the  appendix.  This  plan  also  dim- 
inishes the  liability  of  infecting  the  general  peritoneal  cavity. 

The  appendix  may  be  so  rolled  up  in  a  fold  of  the  great 
omentum  that  it  is  most  difficult  to  decide  which  is  appendix 
and  which  is  omentum.  In  these  cases  it  is  proper  to  tie  ofi^ 
and  cut  away  the  omentum  along  its  attachment  to  the  appen- 
dix, which  last  can  then  be  stripped  loose.  This  method 
ensures  control  of  haemorrhage  from  the  omentum,  and  allows 
greater  ease  in  dealing  with  the  appendix. 

The  appendix  is  often  encapsulated  in  a  mass  of  exudate. 
If  this  cannot  be  stripped  away,  the  thickest  and  firmest 
portion  of  it  is  cut  through,  whereupon  the  organ  can  be 
readily  found,  for  that  part  of  the  exudate  corresponds  to  the 
primary  site  of  inflammation  in  the  appendix. 


150  APPENDICITIS. 

Unless  properly  treated  a  meso-appendix  loaded  with  fat  will 
complicate  the  removal  of  the  appendix,  often  by  troublesome 
bleeding.  A  fat  meso-appendix  is  always  friable  and  liable  to 
tear  in  handling,  especially  in  tying  off.  It  is  best  to  remove 
it  in  sections,  cutting  away  as  the  ligatures  are  tightened. 
This  procedure  minimizes  the  danger  of  tearing  and  the 
resulting  heemorrhage. 

At  times  a  necrotic  or  gangrenous  condition  of  the  apex  of 
the  caecum  is  met  with  where  it  is  impossible  to  find  any  tissue 
healthy  enough  to  hold  stitches  introduced  for  the  purpose  of 
invagination.  Under  these  conditions,  I  pack  off  the  general 
peritoneal  cavity  and  leave  the  gangrenous  patch  in  situ.  In 
a  few  dsLjs  this  separates,  leaving  a  fsecal  fistula  which  can  be 
closed  at  a  subsequent  period  if  repair  does  not  take  place 
spontaneously.  I  consider  this  advisable  rather  than  attempt- 
ing to  remove  the  gangrenous  portion  at  the  time  of  operation 
when  one  cannot  be  sure  of  the  vitality  of  the  tissue  into 
which  the  sutures  are  introduced.  If  the  gangrenous  patch 
be  invaginated  and  the  abdominal  wound  immediately  closed, 
fatal  peritonitis  due  to  perforation  is  imminent. 

Conditions  that  may  complicate  the  course  of  appendicitis  and  in- 
terfere with  recovery. 

Of  these  peritonitis  is  the  most  frequent.  The  prognosis 
depends  upon  the  condition  of  the  peritoneum  at  the  time  of 
operation.  In  all  cases  where  the  disease  has  advanced  beyond 
simple  infection  of  the  mucous  membrane  of  the  appendix, 
inflammation  of  its  serous  coat  is  found ;  this,  of  course,  can 
hardly  be  considered  a  complication. 

Infection  of  the  general  peritoneum,  however,  may  be  the 
result  of  lymphangitis,  of  gangrene,  or  of  perforation  of  the 
appendix  or  caecum.  A  mild  form  is  met  with  in  which  the 
peritoneum  is  injected,  turbid,  and  stick}^  but  where  there 
is   neither   effusion    nor  deposit  of  lymph.     Prognosis   good. 


COMPLICATIONS    AND    SEQUELJ<:.  151 

Again,  the  serous  surfaces  may  be  found  glued  together  and  a 
small  quantity  of  a  turbid  effusion  in  the  cavity.  Prognosis 
good.  If  pus  be  present,  one  of  two  conditions  will  be 
encountered.  In  some,  the  peritoneum  will  be  bathed  in  a 
quantity  of  odorless  pus,  the  serous  surfaces  smooth  and 
shiny,  and  the  coils  of  intestine  not  glued  together.  Prognosis 
fairly  good.  In  others,  the  pus  will  be  less  in  quantity,  but 
of  a  foul  odor ;  the  serous  surfaces  will  be  intensely  injected 
and  of  a  scalded  appearance,  and  large  masses  of  lymph,  in 
different  stages  of  organization,  will  be  abundant.  In  these 
the  streptococci  or  staphylococci  are  always  present.  When 
such  conditions  exist,  the  prognosis  is  unfavorable. 

Obstruction  of  the  bowel  due  to  adhesions,  the  appendix 
itself  acting  as  a  band,  is  a  frequent  complication  of  appendi- 
citis, especially  in  the  chronic  cases.  The  appendix  is  most 
apt  to  be  at  fault  when  holding  some  anomalous  position.  I 
saw  a  case  where  a  band,  the  result  of  chronic  appendiceal 
inflammation,  was  stretched  between  the  appendix  and  a 
Meckel's  diverticulum.  Obstruction  was  caused  by  a  coil  of 
intestine  becoming  engaged  beneath  this  band. 

The  appendix  may  be  found  adherent  to  any  of  the  abdomi- 
nal or  pelvic  viscera.  It  has  even  been  found  attached  to  the 
iliac  blood-vessels.  When  the  appendix  is  attached  to  any  of 
the  abdominal  or  pelvic  viscera,  great  care  must  be  taken  in 
its  removal,  on  account  of  the  haemorrhage  liable  to  ensue. 
Fowler  reports  a  case  in  which  the  gangrenous  process  caused 
by  the  inflammation  of  the  appendix  was  communicated  to 
the  iliac  vein.  The  vein  is  more  often  the  seat  of  the  gan- 
grenous process  than  the  artery. 

Inflammation  or  thrombosis  of  the  right  iliac  vein,  associated 
with  oedema  of  the  corresponding  lower  extremity,  is  a  compli- 
cation sometimes  seen  due  to  a  localized  appendiceal  abscess. 
If  a   fragment   of  the  thrombus  is   carried  into  the  general 


152  APPENDICITIS. 

circulation,  sei^tic  pneumonia  or  general  septicfemia  may  be 
the  result. 

If  the  appendix  is  very  long  and  overhangs  the  brim  of  the 
pelvis,  it  may  lead  to  disease  of  the  pelvic  contents,  although 
such  trouble  may  not  be  recognized  until  some  time  after 
apparent  recovery  from  the  attack  or  until  after  the  removal 
of  the  appendix. 

At  times  an  appendiceal  abscess  will  burrow  upward  behind 
the  liver,  either  through  or  beneath  the  diaphragm,  and  finally 
rupture  into  the  lung  tissue.  I  have  seen  several  cases  where 
the  abscess  following  appendicitis  has  been  evacuated  through 
the  mouth.  The  following  will  be  of  interest  in  this  connec- 
tion : — 

R.  S. ,  male,  age  nineteen,  was  admitted  to  the  Grerman  Hospital,  August 
28,  1895,  with  the  following  history  :  Had  always  enjoyed  good  health  until 
three  days  before  admission,  when  after  a  heavy  meal  he  began  to  suffer 
from  pain  in  the  epigastric  region  attended  by  vomiting,  which  afforded  no 
relief.  Pain  increased  in  severity  and  became  localized  to  the  right  iliac  fossa, 
which  was  markedly  tender  upon  pressure ;  vomiting  ceased  but  nausea  per- 
sisted. 

Patient  thought  himself  suffering  from  mere  colic  and  did  not  summon 
assistance  until  pain  became  unbearable.  Was  immediately  sent  to  the  Ger- 
man Hospital,  where  following  condition  was  noted  :  Temperature  102°  ;  pulse 
94 ;  abdomen  slightly  distended  and  rigid,  especially  upon  the  right  side ; 
pain  diffused  but  tenderness  marked  in  the  right  iliac  fossa,  the  slightest 
touch  causing  the  patient  to  flinch. 

Diagnosis,  appendiceal  abscess. 

By  ice-bags  locally  applied  and  by  free  saline  purgation  the  pain  and  ten- 
derness abated,  and  operation  was  strongly  advised,  but  absolutely  refused  by 
the  parents.  At  this  time  the  temperature  ranged  from  99-99|°,  with  a  cor- 
responding pulse  rate  of  84-100,  the  boy  being  fairly  comfortable  meanwhile, 
despite  occasional  nausea  and  vomiting ;  the  abdomen  continued  tender, 
though  not  to  the  same  degree  as  previously.  He  remained  in  this  condition 
until  the  fourth  day  after  admission  (making  the  seventh  day  from  the  initial 
symptoms),  when  he  grew  suddenly  worse,  the  temperature  rising  to  104°  and 
the  pulse  rate  to  120.  He  vomited  continuously,  and  was  seized  with  dyspnoea, 
expectorating  large  quantities  of  fetid  and  purulent  mucus  tinged  with  blood. 
No  tubercle  bacilli  found.  Patient  became  exhausted  and  died  nine  days 
after  admission.  At  the  post-mortem,  a  perforated  appendix,  pointing  north 
and  lying  just  below  the  diaphragm,  was  found.     The  abscess  surrounding  the 


COMPLICATIONS   AND   SEQUELyE.  153 

appendix  had  penetrated  into  the  lung,  in  which  gangrenous  patches  were 
detected.  The  expectorated  matter  was  evidently  pus  from  the  appendiceal 
abscess. 

In  some  cases  abscess  of  the  liver  is  produced  by  frag- 
ments of  thrombi  being  swept  into  the  portal  or  general  cir- 
culation. When  the  freedom  of  anastomoses  among  the  veins 
of  the  mesentery  is  considered,  it  is  not  strange  that  this  com- 
plication should  occur,  although  it  is  not  as  common  as  might 
be  supposed.  There  may  be  purulent  infection  of  the  pleura 
and  pericardium  as  a  sequence  of  the  abscess  of  the  liver.  If 
the  hepatic  abscess  attains  considerable  size,  it  may  push 
through  the  diaphragm  by  ulceration  and  perforation.  The 
symptoms  attending  this  complication  simulate  those  of 
pleurisy  with  effusion,  or  of  pyo-pericarditis,  or  of  gangrene  of 
the  lune. 


ABSCESS   OF   LIVER— CASE   NOT   OPERATED   UPON. 

The  following  case  came  under  my  notice  only  post-mortem, 
and  I  submit  it  for  several  reasons :  1.  To  show  the  preva- 
lence of  pylo-phlebitis  and  liver  abscess  as  sequelae  of  appendi- 
citis. 2.  To  demonstrate  the  importance  of  first  excluding 
primary  appendiceal  inflammation  in  the  diagnosis  of  all 
abdominal  affections,  particulary  when  pain  and  tenderness 
are  not  referred  to  the  right  iliac  fossa.  3.  To  emphasize  the 
value  that  should  be  attached  to  a  previous  history  of  attacks 
of  colic,  with  gastric  irritation,  as  indicating  early  involve- 
ment of  the  appendix,  from  which,  as  a  source,  remote  organs 
may  become  infected. 

A.  R.,  white,  age  twenty-one,  bartender.  Family  history,  negative. 
Previous  history,  usual  diseases  of  childhood.  During  the  past  eighteen 
months  has  had  three  or  four  attacks  of  colic,  attended  by  vomiting.  No 
mention  was  made  of  localized  pain,  and  in  a  few  days  patient  would  appar- 
ently recover  and  go  about  his  work  as  usual. 

On  March  1st  patient  developed  sore  throat,  with  stiffness  in  all  the 
limbs,  followed  by  excruciating  griping  pains  in  the  epigastrium,  which  were 


154  APPENDICITIS. 

increased  upon  deep  inspiration.  Had  headache  and  backache  ;  also  chill, 
fever,  and  sweats  at  irregular  intervals  ;  appetite  fair  ;  bowels  somewhat  loose. 
When  seen  on  March  15th  by  his  attending  physician  he  presented  the  fol- 
lowing symptoms :  Temperature  103|°,  pulse-rate  96  ;  hectic  flush  on  cheeks  ; 
had  extreme  pain  and  tenderness  over  epigastrium,  and  slight  tympany ; 
rest  of  abdomen,  negative.  Tongue  was  thickly  coated,  pupils  normal ; 
lungs  and  heart  healthy ;  urine  contained  trace  of  albumen  and  a  few 
granular  casts  ;  blood-count  and  haemoglobin  normal,  though  microscopically 
intra-cellular  organisms  resembling  amoeba  of  Laveran  were  noticed. 

On  March  1 6th,  at  5  A.  M. ,  temperature  98°  ;  pulse-rate  80.  Had  had  a 
severe  chill  during  the  night,  with  profuse  sweating  ;  other  symptoms  same, 
except  that  a  serous  diarrhoea  had  set  in. 

Quinine  exhibited  without  relief  There  was  no  change  in  the  symptoms 
until  March  19th.  Morning  temperature  99|°  ;  pulse-rate  104.  However,  a 
diffuse  peritonitis  had  developed,  there  being  extreme  general  abdominal 
tenderness,  tympany,  and  rapid,  irregular  pulse.  Diarrhoea  continued  and 
patient  grew  weaker.  At  5  P.  M. ,  March  20th,  temperature  was  97°  ;  pulse- 
rate  120.     Death  supervened  early  April  4th. 

At  the  post-mortem,  held  eight  hours  after  death,  a  general  peritonitis 
directly  due  to  a  ruptured  liver  abscess  was  found.  The  appendix  was  per- 
forated and  imbedded  in  a  mass  of  gangrenous  adhesions.  Purulent  inflam- 
mation of  the  portal  vein  extended  into  the  liver  substance,  and  in  the  upper 
part  of  the  right  lobe  were  numerous  embolic  abscesses,  one  of  which,  situated 
upon  the  surface  of  the  liver  immediately  beneath  the  diaphragm,  had  rup- 
tured. 

Appendicitis  may  complicate  a  hernia,  and  if  the  latter  is 
strangulated  or  if  a  strangulation  be  suspected,  the  symptoms 
of  the  appendiceal  inflammation  may  be  entirely  lost  sight  of, 
as  the  following  case  will  show : — 

Mrs.  X. ,  set.  forty -two,  admitted  to  the  German  Hospital  with  the  following 
history.  Two  days  previous  she  had  been  attacked  with  general  abdominal 
pain,  associated  with  vomiting  and  absolute  constipation.  The  attending 
physician  found  a  mass  in  the  right  inguinal  canal  which  the  patient  stated 
was  an  old  hernia.  The  mass  was  tender  and  irreducible  by  taxis.  Ether 
was  administered  also  with  no  result.  The  patient  steadily  grew  worse,  and 
the  next  morning  she  was  again  etherized  and  another  attempt  was  made  to 
reduce  the  mass.  This  again  was  futile.  She  was  then  removed  to  the 
hospital,  where  I  saw  her.  The  mass  was  tender  and  inflamed,  the  abdomen 
■was  distended,  the  bowels  were  absolutely  obstructed,  and  vomiting  occurred 
frequently.  Incision  over  the  tumor  showed  that  it  was  but  the  sac  of  an 
old  hernia,  and  not  the  seat  of  the  trouble  at  all.  The  peritoneal  cavity 
was  oj^ened  by  extending  the  original  wound,  and  a  general  purulent  peri- 
tonitis was  found.     But  the  appendix  was  the  seat  of  marked  disease ;   it 


COMPLICATIONS    AND    SEQUELS.  155 

was  removed ;  the  peritoneal  cavity  was  thorouglilj'  irrigated,  drainage 
introduced,  and  the  wound  closed.  The  patient  did  not  rally,  and  died  in 
eighteen  hours.  The  original  site  of  the  inflammation  was  undoubtedly  in 
the  appendix,  but  the  mass  in  the  right  inguinal  canal  had  misled  both  the 
attending  physician  and  myself. 

Abscess  in  the  lumbar  region  may  be  found  as  a  complica- 
tion of  a  purulent  appendicitis,  and  results  from  infection,  by 
direct  continuity,  or  by  the  vessels  going  to  that  region. 

An  abscess  of  the  abdominal  wall,  consequent  upon  an 
appendicitis,  may  be  found ;  this  occurrence,  however,  is  rare. 
The  following  case  will  be  of  interest  in  this  connection : — 

A  boy  of  thirteen  was  referred  to  me  by  my  friend,  Dr.  P.  Moylan,  with  a 
history  of  three  attacks  of  appendicitis.  During  the  last  attack  he  was  under 
the  care  of  Dr.  Moylan,  who  said  to  me  that  at  the  time  of  his  first  visit  a 
general  peritonitis  was  present,  and  was  attended  with  so  much  distention 
that  he  was  unable  to  make  out  by  examination  the  cause  of  the  peritonitis. 
There  was  apparent  recovery  from  this  attack. 

Operation  was  by  incision  through  the  right  semilunar  line,  opening  up  a 
cheesy  mass  situated  beneath  the  transversalis  muscle.  The  peritoneum  be- 
neath the  collection  had  been  destroyed  and  the  posterior  wall  was  formed  by 
the  great  omentum.  The  cheesy  material  was  curetted  away  and  the  cavity 
antisepticized.  The  great  omentum  was  tied  ofi"  around  the  involved  portion 
and  the  latter  cut  away.  The  caecum  contained  two  perforations,  which  were 
brought  to  view  after  the  removal  of  the  diseased  and  adherent  omentum. 
The  appendix  lay  post-caecal,  imbedded  in  a  mass  of  lymph.  It  was  perfor- 
ated at  its  base.  The  pelvis  contained  a  collection  of  pus  which  was  confined 
by  adherent  coils  of  small  bowel. 

The  patient  recovered. 

Pregnancy  may  complicate  appendicitis.  If  the  inflamma- 
tory condition  occurs  during  the  early  stage  of  gestation, 
abortion  generally  follows.  The  usual  risks  of  leaving  a  dis- 
eased appendix  in  the  abdominal  cavity  are  much  increased 
by  the  pregnant  state,  and  the  evil  consequences  of  another 
attack,  i.  e.,  gangrene  or  perforation,  wall  be  correspondingly 
greater.  The  removal  of  the  appendix  is  attended  by  few,  if 
any,  additional  dangers  to  mother  and  foetus. 


156  APPENDICITIS. 

It  is  a  noticeable  fact  that  quite  a  considerable  number  of 
patients  who  are  neurasthenics  suffer  from  appendicitis  in  the 
chronic  form.  Whether  the  dyspepsia,  in  the  widest  sense  of 
that  term,  induced  by  the  appendicitis  leads  to  auto-infection 
and  thus  affects  the  nervous  equilibrium  of  these  patients  must 
at  present  remain  an  open  question.  Some  of  such  patients 
suffer  in  addition  from  colitis -with  mucous  stools,  which  are 
even  sometimes  tinged  with  blood  ;  in  other  cases  the  nervous 
symptoms  are  absent  and  only  the  colitis  may  be  complained 
of. 

Miss  P. ,  age  forty-four,  was  referred  to  me  with  the  following  history : 
For  the  past  three  years  she  had  suffered  from  a  mucous  diarrhoea  which  had 
been  variously  diagnosed  entero-colitis,  dysentery,  etc. ,  and  treated,  without 
benefit,  by  every  method,  from  bismuth  by  mouth  to  quinine  and  nitrate  of 
silver  injections  by  rectum. 

Upon  admission  to  the  German  Hospital  she  was  emaciated  and  markedly 
neurasthenic.  Her  bowel  movements  averaged  four  to  eight  daily,  and  con- 
tained mucus,  shreds  of  mucous  membrane,  and  blood.  Upon  careful  exam- 
ination the  appendix  was  found  enlarged  and  painful  upon  pressure ;  no 
rigidity. 

She  gladly  consented  to  operation  in  the  hope  of  relief,  and  the  appendix, 
when  removed,  was  found  to  be  in  a  typical  state  of  catarrhal  inflammation. 

Recovery  uninterrupted.  However,  the  bloody  and  mucous  stools,  the 
neurasthenia,  and  the  emaciation  did  not  markedly  improve  for  over  three 
months  after  operation,  when  her  symptoms  rapidly  abated.  She  gained 
flesh,  and  within  one  year  she  presented  herself  as  perfectly  cured.  The 
digestive  functions  were  normal,  the  neurasthenia  had  disappeared,  and  she 
had  increased  in  weight  over  twenty  pounds. 

The  removal  of  the  diseased  organ,  which  latter  is  probably 
the  primary  cause  of  these  troubles,  leading  as  it  does  to  inade- 
quate digestion  in  the  large  intestine,  colitis,  etc.,  or  simply  to 
mal-assimilation,  auto-intoxication, and  neurasthenia, is  primar- 
ily only  of  utility  in  removing  the  constant  danger  to  life  by 
which  these  patients  are  threatened. 

The  immediate  effects  of  the  operation  on  both  the  colitis 
and  neurasthenia,  however,  are  not  so  apparent.  It  often  takes 
months  or  even  a  year  and  a  half  before  decided  improvement 


F ,  aged  seventeen  years,  suffered  from  acute  appendicitis  with  abscess. 

At  the  time  of  operation  his  condition  was  very  low  and  it  was  thought 
advisable  to  evacuate  the  abscess  only.  Instead  of  the  abdominal  wall  healing 
completely  there  were  left  two  fistulous  tracts,  from  which  faecal  matter 
escaped  (Fig.  2). 

Ten  weeks  afterward  the  appendix  was  removed,  when  it  was  found  that 
with  the  exception  of  the  tip,  the  upper  half  alone  remained,  these  parts 
being  connected  by  a  band  of  the  meso-appendix  (Fig.  1). 

The  opening  in  the  appendix  was  in  communication  with  the  two  fistulous 
tracts. 

Recovery  followed. 


158 


Fig. 


Plate  xxxii 


Orifice  ir^  coiTirT\unication    ..- 
with  fistulous  tracts 


Fig.  2 


Wf-Y-^iL"- 


Granulations  surrouridirig  fistulous  tracts 


COMPLICATIONS    AND    SEQUELS.  159 

is  noticeable.  But  with  appropriate  treatment  these  patients 
in  the  end  recover. 

After  operation  for  appendicitis  a  constipated  condition  of 
the  bowels  sometimes  supervenes,  which  is  occasionally  quite 
obstinate  and  gives  the  patient  considerable  trouble.  A  sys- 
tematic course  of  gentle  purgation  remedies  this  very  unpleas- 
ant sequelae.  In  this  connection  may  be  mentioned  the  appar- 
ently rational  treatment  by  intestinal  antisepsis.  If  a  drug  or 
a  method  of  treatment  were  known  by  which  the  intestinal 
tract  could  be  sterilized,  no  doubt  the  most  gratifying  results 
would  be  obtained.  But,  unfortunately,  the  various  drugs,  as 
naphthalin,  creasote,  etc.,  or  high  enemata,  have  proven  quite 
inadequate,  while  some  of  the  drugs  employed  are  even  dan- 
gerous. 

These  considerations  emphasize  the  necessity  for  the  physi- 
cian to  carefully  examine  even  slight  cases  of  colitis,  mucous 
enteritis,  neurasthenia,  and  allied  disorders  for  possible  appen- 
dicitis, since  it  is  rational  to  expect  that  the  sooner  the  cause 
of  these  various  ailments  is  removed  the  sooner  will  the  patient 
be  cured  of  these  disagreeable  and  annoying  sequelse. 

Fsecal  fistula  is  the  most  frequent  and  the  most  annoying  of 
the  sequelse  of  appendicitis.  In  pus  cases  this  is  often  due  to 
the  appendix  being  allowed  to  remain  after  evacuating  the  abscess; 
in  others,  it  is  due  to  a  gangrenous  area  of  the  caecum  which 
was  too  large  to  close  in  at  the  time  of  the  operation,  or 
which  developed  after  the  removal  of  the  appendix  as  a  result 

of  the  original  disease  (see  case  of  F ,  Plate  XXXII).     A 

second  operation  may  sometimes  be  necessary  to  abolish  the 
fistula,  but  generally  it  heals  without  surgical  interference. 
Fistulse  appearing  early  after  the  operation  show  much  greater 
tendency  to  spontaneous  closure  than  those  supervening  after 
some  time  has  elapsed. 


160  APPENDICITIS. 

Hernia,  following  the  operation,  may  occur  in  those  cases 
where  it  had  been  necessary  to  introduce  drainage.  Some 
surgeons  claim  that  they  have  never  seen  a  hernia  as  a  sequel 
of  the  operation,  but  this  has  not  been  my  experience. 

Where  drainage  has  been  introduced  the  wound  closes  by 
granulations,  leaving  cicatricial  tissue  which  is  decidedly  weak 
and  unable  to  stand  the  strain  exerted  upon  it  by  the  intra- 
abdominal pressure.  I  have  never  seen  a  hernia  follow  the 
McBurney  operation,  however,  and  seldom  the  ordinary  opera- 
tion, for  if  the  wound  can  be  closed  immediately,  the  careful 
introduction  of  sutures  will  almost  always  prevent  it.  The 
relative  frequency  of  hernia  following  pus  cases  with  drainage 
is,  of  course,  another  argument  for  early  operation. 

While  it  may  be  a  simple  matter  to  operate  upon  a  patient 
who  has  a  hernia  the  result  of  an  appendicectomy,  it  should, 
nevertheless,  be  borne  in  mind  that  any  operation,  however 
slight,  is  attended  by  danger ;  therefore,  should  a  patient  be 
subjected  to  the  risk  of  a  secondary  operation,  when  one  per- 
formed before  pus  formation  will  obviate  this  necessity  ? 

A  truss  applied  with  the  idea  of  curing  or  relieving  these 
hernise  causes  more  damage  than  benefit,  as  the  pressure  thins 
the  abdominal  wall  and  makes  a  future  operation  less  likely  to 
be  successful.  If  a  hernia  occurs  after  the  operation  for  appen- 
dicitis, I  believe  it  more  satisfactory  to  immediately  correct  this 
defect. 

When  infiltration  of  the  abdominal  wall  is  found  during 
operation,  it  generally  signifies  the  presence  of  collections  of 
pus.  This  infiltration  is  confined  to  the  deeper  structures 
mainly,  the  muscular  tissue  and  transversalis  fascia,  from 
both  of  which  serum  exudes  upon  section.  This  exudation  is 
pathognomonic  of  pus,  and  the  peritoneum  beneath  is  found 
infiltrated,  thickened,  and  at  times  the  pus  is  visible  through  it. 


AFTER-TRE  ATMEN  T. 

Since  the  welfare  of  the  patient  after  the  operation  for  appen- 
dicitis depends  upon  close  attention  to  details,  the  treatment 
outlined  below  may  be  considered  as  a  safe  guide. 

The  cases  conveniently  divide  themselves  into — 

1.  Simple,  uncomjDlicated  cases  in  which  the  wound  is  closed 
throughout  at  the  time  of  operation. 

2.  Cases  in  which  glass  or  rubber  drainage  is  used. 

3.  Cases  in  which  gauze  is  allowed  to  remain  in  the  abdom- 
inal cavity,  either  for  drainage  or  for  protection  of  the  general 
peritoneum. 

For  all  cases,  however,  the  following  directions  apply : — 
Patient  should  be  isolated  and  under  charge  of  a  competent 
nurse.  Temperature  and  pulse-rate  should  be  taken  every 
three  hours  for  first  two  days. 

After-effects  of  ether,  as  vomiting,  tossing  about  in  bed, 
should  be  guarded  against.  If  great  restlessness  develops, 
knees  should  be  tied  together  by  a  towel. 

Patient  should  be  kept  warm  by  hot  bottles. 

Body  should  be  protected  against  pressure  of  bed-clothes  by 
a  bed-cradle. 

Rubber  air-ring  under  gluteal  region  is  a  great  comfort  to 
the  patient  and  relieves  the  pain  in  the  back  that  is  constantly 
complained  of. 

Urine  should  be  drawn  by  catheter,  if  necessary,  and  care- 
fully examined. 

If  stimulation  is  necessary,  hypodermatic  injections  of  strych- 
nia (^),  atropia  (yo-q)'  ^^^  whiskey  (syringeful)  may  be 
employed. 

11  161 


162  APPENDICITIS. 

No  MORPHIA. 

Absolutely  nothing  by  mouth  for  the  first  four  hours.  After 
that  small  pieces  of  ice  may  be  given  at  fifteen  minutes'  inter- 
vals and  the  mouth  and  lips  occasionally  cooled  by  a  moist 
cloth. 

N"o  nourishment  should  be  given  for  at  least  the  first 
eighteen  hours  after  operation.  If  at  the  expiration  of  that 
time  the  stomach  shows  no  evidence  of  irritability,  tablespoon 
doses  of  peptonized  milk  with  a  teaspoonful  of  whiskey  are 
cautiously  given  every  two  hours,  which  quantities  are  grad- 
uall}^  increased  according  to  individual  circumstances.  If 
vomiting  supervenes  during  this  period  absolute  abstinence 
for  a  time  is  again  necessary. 

For  the  relief  of  pain,  which  is  always  present,  and  which  is 
due  in  most  cases  to  intestinal  distention,  asafoetida  supposi- 
tories (gr.  V  e'ach)  may  be  given  as  required ;  or  if  these  fail, 
enemata  containing  two  ounces  of  milk  of  asafoetida  and  three 
or  four  ounces  of  warm  water  ma}''  be  injected,  usually  with 
marked  benefit. 

Calomel,  gr.  \,  with  bicarbonate  of  soda,  gr.  ^,  in  powders, 
are  begun  twenty-four  hours  after  operation  at  hourly  intervals, 
and  continued  until  eight  are  taken. 

Persistent  vomiting,  which  is  liable  to  develop  in  any  case, 
is  treated  by  the  application  of  a  fly  blister  (two  inches  square) 
over  the  epigastrium ;  or  b}^  one-quarter  grain  doses  of  cocaine 
every  two  hours ;  or  by  teaspoonful  doses  of  hot,  strong,  black 
coffee.     Iced  champagne  may  be  of  service. 

We  may  now  consider  in  greater  detail  the  classification 
above  mentioned : — 

1.  Simple  Cases. — If  the  temperature  and  the  general  condi- 
tion of  the  patient  show  no  abnormality  the  wound  requires 
no  attention  for  tlie  first  five  days.  After  that  the  dressing  is 
removed,  the  stitches  are  taken  out,  and  a  simple  aseptic  dress- 


AFTER-TREATMENT.  163 

ing  is  applied  and  allowed  to  remain  for  from  three  to  five 
days.  An  abdominal  supporter  is  then  put  on  and  the  patient 
permitted  to  leave  bed. 

A  sharp  rise  of  temperature  or  much  local  pain  with  disten- 
tion necessitate  immediate  renewal  of  the  dressing,  at  which 
time  a  careful  search  should  be  instituted  for  the  source  of 
irritation. 

Stitch  abscesses  should  be  opened  and  treated  on  general 
antiseptic  principles.  If  pus  has  formed,  the  case  merges  into 
one  of  the  varieties  described  below. 

2.  Cases  in  ivhich  Glass  or  Rubber  Drainage  is  Used. — Since 
this  method  of  drainage  follows  long  and  exhausting  operations, 
careful  attention  to  stimulation  is  necessary.  If  much  blood 
has  been  lost  and  there  are  evidences  of  exsanguination,  hypo- 
dermoclysis  should  be  employed  and  from  six  to  20  ounces  of  a 
normal  salt  solution,  at  temperature  of  100°,  should  be  injected, 
preferably  over  the  infra-clavicular  or  inguinal  regions. 

The  glass  drainage  tube  should  be  cleaned  sufficiently  often 
to  avoid  a  large  collection  of  fluid  in  the  pelvis.  When,  after 
a  three-hour  interval,  the  fluid  withdrawn  is  of  an  amber  color 
and  not  more  than  one  drachm  in  amount,  the  tube  should  be 
aseptically  removed  and  the  stitches,  previously  introduced 
and  left  untied,  should  now  be  drawn  together  and  the  wound 
closed. 

The  case  thus  becomes  a  simple  one  and  should  be  so  treated. 

Rubber  Drainage. — In  these  cases  the  cavity  is  carefully 
syringed  daily  with  a  warm  five  per  cent,  boric  acid  solution 
and  the  tube ,  gradually  withdrawn.  After  its  removal  the 
wound  is  closed  and  treated  as  above. 

3.  Gauze  .Drainage. — The  dressing  is  left  undisturbed  until 
the  second  day  after  operation.  At  this  time  the  pieces  of 
gauze  remaining  within  the  cavity,  having  been  carefully  and 
thoroughly  softened  by  copious  applications  of  a  warm  five 


164  APPENDICITIS. 

per  cent,  boric  acid  or  normal  saline  solution,  are  cautiously 
disengaged  from  adhesions  and  very  slowly  withdrawn.  The 
cavity  is  then  gently  irrigated,  packed  with  iodoform  gauze,  and 
dressed  aseptically.  The  next  dressing  takes  place  after  two 
days  in  the  same  manner.  If  the  cavity  is  then  clean  the 
sutures  Inserted  at  the  time  of  operation  may  be  tied  and  the 
wound  closed  as  above. 

In  the  vast  majority  of  cases  involvement  of  the  general 
peritoneum  does  not  occur.  Occasionally,  however,  as  the 
result  of  perforation  or  lymphatic  infection,  or  when  it  is  pres- 
ent at  the  time  of  operation,  this  condition  demands  vigorous 
treatment.  In  such  cases  we  are  of  the  opinion  that  the  local 
application  of  ice  bags  with  calomel  purgation  and  susjDension 
of  nourishment  b}''  mouth  offer  the  best  chance  of  recovery. 
While  salines  would  be  better  adapted  for  draining  the 
engorged  peritoneal  vessels,  unfortunately  the  stomach  will 
not  often  tolerate  them. 

AVhen  the  constitutional  condition  indicates  it,  nutritious 
enemata  of  peptonized  milk,  bouillon,  eggs,  etc.,  may  be  of 
service. 

In  conclusion,  it  may  be  fitting  to  say  that  my  attitude  in 
the  consideration  of  appendiceal  surgery  is  the  result,  not  of 
theoretical  deductions,  but  of  that  best  of  teachers — experience. 
Therefore,  after  a  close  observation  of  over  500  of  my  own 
operative  cases  I  give  the  foregoing  views  as  my  earnest  con- 
victions. 


INDEX. 


A  BSCESS,  appendix  in  wall  of,  56 

appendiceal,  137 

varieties  of,  137 

extending  behind  liver,  153 

of  liver,  153 

in  lumbar  region,  155 

of  abdominal  wall,  155 

psoas,  110 

lumbar,  111 

splenic,  107 

hepatic,  108 

of  abdominal  wall,  108 

of  kidney,  101 
Acute  appendicitis,  symptoms  of,  73 
Abdominal  wound,  closure  of,  142 

dressing  of,  145 
Adhesions,  formation  of,  56 
J5tiology,  31 
After-treatment,  161 

in  simple  cases,  162 

in   cases  in   which   drainage  is 
used,  163 
Age  as  predisposing  cause,  33 
Albers,  investigations  of,  20 
AuEesthesia,  149 
Anatomy,  23 
Appendiceal  abscess,  137 

varieties  of,  137 

extending  behind  liver,  152 
Appendiculo-ovarian  ligament,  26 
Appendix,  types  of,  23 

anatomy  of,  23 

peritoneal  covering  of,  25 

abnormal  position  of,  28 

structure  of,  28 

blood-supply  of,  30 

nerves  of,  30-64 


Appendix,  position  predisposing   to 
inflammation,  32 
palpation  of,  81 
Asafcetida  suppositories,  121 


1)ACTEEI0L0GY,  70 

Biliary  colic.  111 
Blisters  contra-indicated,  121 
Blood-supply  of  appendix,  30 
Bristow,  definition  of  position,  27 
Burne,  investigation  of,  19 


nJECTJM,  peritoneal  covering  of,  24 

cancer  of,  103 

perforation  of,  126 
Calomel  as  laxative,  117 
Canal,  obliteration  of,  49 
Cancer  of  caecum,  103 
Castor-oil  as  laxative,  117 
Causes,  predisposing,  31 

exciting,  37 
Chill  as  symptom  of  pus-formation, 

91 
Chronic  appendicitis,  81 

typhlitis,  20 
Closure  of  abdominal  wound,  142 
Cold  applications,  120 
Colitis,  107 

accompanying  appendicitis,  156 
Complications,  148 

of  operative  treatment,  148 

interfering  with  recovery,  150 
Concretions,  fajcal,  as  exciting  cause, 
38 


165 


166 


INDEX. 


Constipatiou  as  symptom,  78 
following  operation,  159 
Copland,  investigations  of,  19 


niAGNOSIS,  84 

differential,  94 
Diet  in  acute  appendicitis,  121 

in  chronic  appendicitis,  122 
Differential  diagnosis,  94 
Distention,  90 

of  abdomen  as  symptom,  79 
Drainage-tube,  use  of,  in  evacuating 

pus,  139-142 
Dressing  of  abdominal  wound,  145 
Dupuytren,  investigation  of,  19 
Dysentery,  107 


PAELY  operation,  reason  for,  124 

Endo-appendicitis,  45 
Enemata,  indications  for,  121 
Enlarged  mesenteric  gland,  109 
Epigastric  veins,  ligation  of,  146 
Etiology,  see  Etiology,  31 
Examination,  rectal,  85 

vaginal,  85 
Exposure    to    cold    as    predisposing 

cause,  34 
Extension  of  pus  formation,  59 
Extra-uterine  pregnancy,  98 


FAECAL     concretions    as    exciting 
cause,  38 

fistula,  159 
Ferrall,  monograph  by,  18 
Fibroid  tumor,  97 
Fitz,  investigations  of,  21 
Floating  kidney,  99 

with  a  twisted  pedicle,  100 
Follicular    abscesses    of     appendix 

simulating  typhoid,  95 
Foreign  bodies  as  exciting  cause,  37 
Fossa,  ileo-colic,  26 

ileo-ca^cal,  26 

sub-ctecal,  27 


Fourth  stage  of  disease,  59 
Fowler,  definition  of  position,  27 
Fulness,  89 

as  symptom,  89 


n  ALL-BLADDER,  rupture  of,  108 

Gall-stones,  111 
Gangrene,  caused  by  pressure,  55 

from  interference   with  circula- 
tion, 63 

by  pressure  of  concretion,  43 
Gastric  ulcer,  103 

Gauze,  disposition  of  during  opera- 
tion, 137,  142,  145 
GrisoUe,  cases  reported  by,  20 


TJiEMATOCELE,  mesenteric,  109 
Hancock,  operation  by,  21 

Hepatic  abscess,  108 

Hernia  following  operation,  160 
incipient  inguinal,  109 

Hip-joint  disease,  110 

History,  17 

Hodenpyl,  investigations  of,  71 

Hot  applications,  120 

Husson  and  Dance,  18 


TLEO-C^CAL  fossa,  26 

Ileo-colic  fossa,  26 
Incision,  simple,  132 

McBurney,  133 
Indigestion  as  exciting  cause,  37 
Infiltration  of  abdominal  wall,  si§ 

nificauce  of,  160 
Inflammation,  spread  of,  63 
Instruments  required,  146 
Intestinal  obstruction,  103 
Iodine  contra-indicated,  120 


T7IDNEY,  abscess  of,  101 
growths  of,  101 


neoplasms  of,  101 


INDEX. 


167 


T  AENNEC,  investigations  of,  17 
Laxatives,  116,  118 
purposes  of,  117 
Leeches  contra-indicated,  120 
Leucocytosis  as  symptom,  81 
Ligament,  appendiculo-ovarian,  26 
Location  of  pain,  75,  86 
Lumbar  abscess,  111 


McBURNEY'S  incision,  133 
operation,  133 

advantages  of,  135 
Melier,  cases  reported  by,  18 
Menopause,  99 
Menstruation,  painful,  98 
Mesenteric  bsematocele,  109 

gland,  enlarged,  109 
Meso-appendix,  anatomy  of,  25 
Mestivier,  investigations  of,  18 
Micro-organisms  as  exciting  cause,  37 

of  typhoid  fever,  72 

of  tuberculosis,  72 

of  actinomycosis,  72 
Muscularis  mucosse,  29 


"M"EOPLASMS  of  kidney,  101 

Nephritic  colic,  100 
Nerve-supply  of  appendix,  30 
Neurasthenia  accompanying  appen- 
dicitis, 156 
Noyes,  reports  by,  21 


ABSTRUCTION  of  bowels  follow- 
ing operation,  151 

intestinal,  103 
Operation,  favorable  time  for,  125 

reasons  for  delaying,  123 

in  presence  of  pus,  136 

preparation  for,  140 
Opium,  why  contra-indicated,  118 

contra-indicated,  84 
Ovarian  cyst,  suppurating,  97 

abscess,  96 


pAIN,  position  of,  86 

character  of,  76 

as  a  symptom,  73 

location  of,  75 
Painful  menstruation,  98 
Palpation  of  appendix,  81 

Edebohl's  method  of,  81 
Para-appendicitis,  45 
Parietal  appendicitis,  45 
Parker,  reports  by,  21 
Pathology,  45 

Perforation  by  pressure  of  concretion, 
43 

of  alimentary  tract,  103 

of  caecum,  126 

from  pressure,  50 
Peri-appendicitis,  45 
Peri-nephritic  abscess,  101 
Peritoneal  covering  of  appendix,  25 

caecum,  24 
Peritonitis  following  operation,  150 

tubercular,  107 
Peri-typhlitis,  20 
Pleurisy,  111 
Pneumonia,  111 

Position  predisposing  to  inflamma- 
tion, 32 
Predisposing  causes,  31 
Pregnancy  complicating  appendicitis, 

155 
Prognosis,  113 
Psoas-abscess,  110 
Pulse-rate  as  symptom,  78 
Pus,  circumscribed  collection  of,  110 

extension  of,  59 
Pyo  nephrosis,  101 
Pyo-salpinx,  96 


"DECTAL  examination,  85 

Eenal  irritation  of  appendicitis, 
100 
Eespiration  as  symptom,  80 

in  acute  appendicitis,  91 
Eestlessness  as  symptom,  79 
Eibbert,  statistics  of,  49 
Eichardson's  method  of  diagnosis,  79 


168 


INDEX. 


Rigidity  of  abdominal  walls  as  symp- 
tom, 77 
Rokitansky,  investigation  of,  20 
Euptnre  of  gall  bladder,  108 


a  ALTS  as  laxative,  118 

Second  stage  of  disease,  55 
Sequelae,  148 

Sex  as  predisposing  cause,  33 
Simple  incision,  132 
Splenic  abscess,  107 
Spots,  significance  of,  94 
Stercoral  typhlitis,  20 
Structure  of  appendix,  28 

as  predisposing  cause  of  inflam- 
mation, 31 
Sub-csecal  fossa,  27 
Suppurating  ovarian  cyst,  97 
Sutures,  materials  for,  142 

mattress,  introduction  of,  143 

objections  to,  144 

simple,  introduction  of,  143-145 

advantages  of,  144 
Symptoms,  73 


npEMPERATURE  as  symptom,  78 
Tenderness  as  symptom,  76 
location  of,  84 
in  presence  of  pus,  86 

Third  stage  of  disease,  56 


Tongue,  condition  of,  as  symptom, 

79 
Treatment,  116 
Tubercular  peritonitis,  107 
Tumescence,  90 

as  symptom,  79 
Turpentine  stupes,  120 
Typhlitis,  stercoral,  20 
simple,  20 
chronic,  20 

named  by  Fitz  ' '  Appendicitis, ' ' 
22 
Typhoid  fever,  94 

as  predisposing  cause,  34 


TTLCERATION  of  lining  membrane, 

55 
Ulcer,  gastric,  103 
Ureteritis,  101 
Urine,  condition  of  as  symptom,  80 

examination  of,  102 


VAGINAL  examination,  85 

Villermey,  case  reported  by,  18 
Voltz,  monograph  by,  20 
Vomiting  as  symptom,  77 


WOUND,  abdominal  closure  of,  142 
abdominal  dressing  of,  145 


CATALOGUE 
No.  1. 


READ  "SPECIAL  NOTE"   BELOW. 

JUNE,  1896. 


CATALOGUE 

OF 

Medical,  Dental, 

Pharmaceutical,  and  Scientific  Publications, 

WITH    A    SUBJECT    INDEX, 

OF  ALL  BOOKS  PUBLISHED  BY 

P.  BLAKISTON,  SON  &  CO. 

(Successors  to  Lindsay  &  Blakiston), 

PUBLISHERS,    IMPORTERS,    AND     BOOKSELLERS, 

IOI2  WALNUT  ST.,  PHILADELPHIA. 


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Nose  and  Ear. 

Hatfield.     Children. 
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Dictionary  of.     5th  Ed.  4.50 

Heath.     Dis.  of  Jaws.        -     4.50 

Lectures  on  Jaws.  Bds.    .50 

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Talbot.  Irregularity  of  Teeth.  3.00 
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Metallurgy.     Illus.         -  1.25 


.40 


50 


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Harris'  Dental.  Clo.  4.50;  Shp.  5.50 
Longley's  Pronouncing.  .75 

Maxwell.  Terminologia  Med- 
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Treves.     German-English.        3.25 

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Dalby.    Diseases  of.    4th  Ed.  2.50 
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Hovell.     Treatise  on.  -      5  00 

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Richardson's  Long  Life.  .40 

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Coplin  and  Bevan.     Practi- 
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Fox.     Water,  Air,  Food.  3.50 

Kenwood.      Public     Health 

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lation  Hospitals. 
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COBLENTZ.  Manual  of  Pharmacy.  A  Text-Book  for  Students.  By  Virgil 
CoBLENTZ,  A.M.,  PH.G.,  PH.D.,  Professor  of  Theory  and  Practice  of  Pharmacy, 
Director  of  Pharmaceutical  Laboratory,  College  of  Pharmacy  of  the  City  of 
New  York.  Second  Edition,  Revised  and  Enlarged.  437  Illustrations.  Octavo. 
572  pages.  Cloth,  $3.50 

COHEN.  The  Throat  and  Voice.   By  J.  Solis-Cohen,  m.d.  Illus.  i2mo.   Cloth,  .40 

COLLIE,  On  Fevers.  A  Practical  Treatise  on  Fevers,  Their  History,  Etiology, 
Diagnosis,  Prognosis,  and  Treatment.  By  Alexander  Collie,  m.d.,  m.r.c.p., 
Lond.,  Medical  Officer  of  the  Homerton  and  of  the  London  Fever  Hospitals. 
With  Colored  Plates.     i2mo.  Cloth,  $2.00 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  9 

COOPER.  Syphilis.  By  Alfred  Cooper,  f.r.c.s.,  Senior  Surgeon  to  St.  Mark's 
Hospital ;  late  Surgeon  to  the  London  Lock  Hospital,  etc.  Edited  by  Edward 
CoTTERELL,  F.R.C.S.,  Surgeon  London  Lock  Hospital,  etc.  Second  Edition. 
Enlarged  and  Illustrated  with  20  Full-page  Plates  containing  many  handsome 
Colored  Figures.     Octavo.  Cloth,  $5.00 

COPLIN  and  SEVAN.  Practical  Hygiene.  By  W.  M.  L.  Coplin,  m.d..  Adjunct 
Professor  of  Hygiene,  Jefferson  Medical  College,  Philadelphia,  and  D.  Bevan, 
M.D.,  Ass't  Department  of  Hygiene,  Jefferson  Medical  College;  Bacteriologist, 
St.  Agnes'  Hospital,  Philadelphia,  with  an  Introduction  by  Prof.  H.  A.  Hare, 
and  articles  on  Plumbing,  Ventilation,  etc.,  by  Mr.  W.  P.  Lockington,  Editor  of 
the  Architectural  Era.     138  Illustrations,  some  of  which  are  in  colors.     8vo. 

Cloth,  ^3.25 

CROCKER.  Diseases  of  the  Skin.  Their  Description,  Pathology,  Diagnosis,  and 
Treatment,  with  special  reference  to  the  Skin  Eruptions  of  Children.  By  H, 
Radcliffe  Crocker,  m.d..  Physician  to  the  Dept.  of  Skin  Diseases,  University 
College  Hospital,  London.  92  Illustrations.  Second  Edition.  Enlarged.  987 
pages.     Octavo.  Cloth,  $4.50 

CTJLLINGWORTH.    A  Manual  of  Nursing,  Medical  and  Surgical.    By  Charles 

J.  CuLLiNGWORTH,    M.D.,    Physician  to  St.  Thomas'  Hospital,  London.     Third 

Revised  Edition.     With  Illustrations.     i2mo.  Cloth,  .75 

A  Manual  for  Monthly  Nurses.    Third  Edition.    32mo.  Cloth,  .40 

DALBY.  Diseases  and  Injuries  of  the  Ear.  By  Sir  William  B.  Dalby,  m.d., 
Aural  Surgeon  to  St.  George's  Hospital,  London.  Illustrated.  Fourth  Edition. 
With  38  Wood  Engravings  and  8  Colored  Plates.  Cloth,  $2.50 

DAVIS.  Biology.  An  Elementary  Treatise.  By  J.  R.  Ainsworth  Davis,  of 
University  College,  Aberystwyth,  Wales.   Thoroughly  Illustrated.    i2mo.      ^3.00 

DAVIS.  A  Manual  of  Obstetrics.  Being  a  complete  manual  for  Physicians  and 
Students.  By  Edward  P.  Davis,  m.d..  Professor  of  Obstetrics  and  Diseases  of 
Infancy  in  the  Philadelphia  Polyclinic,  Clinical  Lecturer  on  Obstetrics,  Jeffer- 
son Medical  College ;  Professor  of  Diseases  of  Children  in  Woman's  Medical 
College,  etc.  Second  Edition,  Revised.  With  16  Colored  and  other  Lithograph 
Plates  and  134  other  Illustrations.     i2mo.  Cloth,  $2.00 

DAVIS.    Essentials  of  Materia  Medica  and  Prescription  Writing.    By  J. 

Aubrey  Davis,  m.d.,  Ass't  Dem.  of  Obstetrics  and  Quiz  Master  in  Materia 
Medica,  University  of  Pennsylvania;  Ass't  Physician,  Home  for  Crippled  Chil- 
dren, Philadelphia.  i2mo.  |i-5o 
DAY.  On  Headaches.  The  Nature,  Causes,  and  Treatment  of  Headaches.  By 
Wm.  H.  Day,  m.d.     Fourth  Edition.     Illustrated.     8vo.                        Cloth,  $1.00 

DEAVER.     Appendicitis.     Its  History,  Anatomy,  Etiology,  Pathology,  Symptoms, 
Diagnosis,  Prognosis,  Treatment,  Complications,  and   Sequelae.      By  John   B. 
Deaver,  m.d..  Assistant  Professor  of  Applied  Anatomy,  University  of  Pennsyl- 
vania;  Surgeon  to  the  German  Hospital,  to  the  Children's  Hospital,  and  to  the 
Philadelphia  Hospital  ;    Consulting  Surgeon  to  St.  Agnes',  St.  Timothy's,  and 
Germantown  Hospitals,  etc.    A  Systematic  Treatise,  with  Colored  Illustrations  of 
Methods  of  Procedure  in  Operating  and  Plates  of  Typical  Pathological  Condi- 
tions drawn  specially  for  this  work.  Cloth,  $3.50 
Surgical  Anatomy.     A  Treatise  upon  Surgical  Anatomy  and  the  Anatomy 
of  Surgery.     Illustrated  by   upward   of  200  Original  Pictures  drawn  by  a 
special  artist  from  dissections  made  for  the  purpose.     Octavo.  In  Press. 

DOMVILLE.  Manual  for  Nurses  and  others  engaged  in  attending  to  the  sick.  By 
Ed.  J.  Domville,  m.d.  Eighth  Edition.  Revised.  With  Recipes  for  Sick- 
room Cookery,  etc.     i2mo.  Cloth,  .75 

DUCKWORTH.  On  Gout.  Illustrated.  A  treatise  on  Gout.  By  Sir  Dyce 
Duckworth,  m.d.  (Edin.),  f.r.c.p..  Physician  to,  and  Lecturer  on  Clinical 
Medicine  at,  St.  Bartholomew's  Hospital,  London.  With  Chromo-lithographs 
and  Engravings.     Octavo.  Cloth,  |6.oo 


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DtJHRSSEN.  A  Manual  of  Gynecolog-ical  Practice.  By  Dr.  A.  Duhrssen, 
Privat-docent  in  Midwifery  and  Gynecology  in  the  University  of  Berlin.  Trans- 
lated from  the  Fourth  German  Edition  and  Edited  by  John  W.  Taylor,  f.r.c.s., 
Surgeon  to  the  Birmingham  and  Midlands  Hospital  for  Women ;  Vice-President 
of  the  British  Gynecological  Society ;  and  Frederick  Edge,  m.d.,  m.r.c.p., 
F.R.C.S.,  Surgeon  to  the  Wolverhampton  and  District  Hospital  for  Women.  With 
105  Illustrations.     i2mo.  Cloth,  $1.50 

DULLES.  "What  to  Do  First,  In  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d. 
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PICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  A  Handbook  for  Physicians 
and  Students.  By  Dr.  Eugen  Fick,  University  of  Zurich.  Authorized  Transla- 
tion by  A.  B.  Hale,  m.d.,  Assistant  to  the  Eye  Department,  Post-Graduate  Medi- 
cal School,  Chicago;  late  Vol.  Assistant,  Imperial  Eye  Clinic, University  of  Kiel. 
With  a  Glossary  and  157  Illustrations,  many  of  which  are  in  colors.        In  Press. 

FIELD.  Evacuant  Medication — Cathartics  and  Emetics.  By  Henry  M.  Field, 
M.D.,  Professor  of  Therapeutics,  Dartmouth  Medical  College,  Corporate  Mem- 
ber Gynaecological  Society  of  Boston,  etc.     i2mo.     288  pp.  Cloth,  $1.75 

FILLEBROWN.  A  Text-Book  of  Operative  Dentistry.  Written  by  invitation 
of  the  National  Association  of  Dental  Faculties.  By  Thomas  Fillebrown,  m.d., 
D.M.D.,  Professor  of  Operative  Dentistry  in  the  Dental  School  of  Harvard  Uni- 
versity ;  Member  of  the  American  Dental  Assoc,  etc.    Illus.    8vo.      Clo.,  $2.25 

FLAGG.  Plastics  and  Plastic  Fillings,  as  pertaining  to  the  filling  of  all  Cavities 
of  Decay  in  Teeth  below  medium  in  structure,  and  to  difficult  and  inaccessible 
cavities  in  teeth  of  all  grades  of  structure.  By  J.  Foster  Flagg,  d.d.s..  Professor 
of  Dental  Pathology  in  Philadelphia  Dental  College.  Fourth  Revised  Edition. 
With  many  Illustrations.     8vo.  Cloth,  $i|. 00 

FOWLER'S  Dictionary  of  Practical  Medicine.  .By  Various  Writers.  An  Ency- 
clopedia of  Medicine.  Edited  by  James  Kingston  Fowler,  m.a.,  m.d.,  f.r.c.p., 
Senior  Asst.  Physician  to,  and  Lecturer  on  Pathological  Anatomy  at,  the  Mid- 
dlesex Hospital,  London.     8vo.  Cloth,  ^3.00 ;  Half  Morocco,  I4.00 

FOX.  Water,  Air  and  Food.  Sanitary  Examinations  of  Water,  Air  and  Food. 
By  Cornelius  B.  Fox,  m.d.    i  10  Engravings.    2d  Ed.,  Revised.        Cloth,  I3. 50 

FOX   AND   GOULD.     Compend  on  Diseases  of  the  Eye  and  Refraction, 

including  Treatment  and  Surgery.  By  L.  Webster  Fox,  m.d.,  late  Chief  Clini- 
cal Assistant,  Ophthalmological  Department,  Jefferson  Medical  College  Hospital, 
etc.,  and  Geo.  M.  Gould,  m.d.  Second  Edition.  Enlarged.  71  Illustrations  and 
39  Formulas.     Being  No.  8,  f  Quiz- Compend?  Series. 

Cloth,  .80.     Interleaved  for  the  addition  of  notes,  $1.25 

FULLERTON.     Obstetric  Nursing.     By  Anna  M.  Fullerton,  m.d..   Demon- 
strator of  Obstetrics  in  the  Woman's  Medical  College ;    Physician    in   charge 
of,  and  Obstetrician  and  Gynecologist  to,  the  Woman's  Hospital,  Philadelphia, 
etc.  40  Illustrations.    Fourth  Edition.    Revised  and  Enlarged.   i2mo.  Cloth,  ^i.oo 
Nursing  in  Abdominal  Surgery  and  Diseases  of  Women.    Comprising  the 
Regular  Course  of  Instruction  at  the   Training   School  of  the  Woman's 
Hospital,  Philadelphia.    Second  Ed.     70  Illustrations.     i2mo.     Cloth,  $1.50 

GARROD.  On  Rheumatism.  A  Treatise  on  Rheumatism  and  Rheumatic  Arthritis. 
By  Archibald  Edward  Garrod,  m.a.  (Oxon.),  m.d.,  m.r.c.s.  (Eng.),  Asst. 
Physician,  West  London  Hospital.     Illustrated.     Octavo.  Cloth,  $5.00 

GARDNER.    The  Brewer,  Distiller  and  Wine  Manufacturer.    A  Handbook  for 

all  Interested  in  the  Manufacture  and  Trade  of  Alcohol  and  Its  Compounds. 

Edited  by  John  Gardner,  f-c.s.     Illustrated.  Cloth,  $1.50 

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MEDICAL  AND  SCIENTIFIC  PUBLIC  A  TIONS.  11 

GILLIAM'S  Pathology.  The  Essentials  of  Pathology ;  a  Handbook  for  Students. 
By  D.  Tod  Gilliam,  m.d.,  Professor  of  Physiology,  Starling  Medical  College, 
Columbus,  O.    With  47  Illustrations.    i2mo.  Cloth,  .75 

GORGAS'S  Dental  Medicine.  A  Manual  of  Materia  Medica  and  Therapeutics. 
By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s.,  Professor  of  the  Principles  of  Dental 
Science,  Dental  Surgery  and  Dental  Mechanism  in  the  Dental  Dep.  of  the  Univ. 
of  Maryland.     Fifth  Edition.     Revised  and  Enlarged.     8vo.  Cloth,  $4.00 

GOULD.    The  Illustrated  Dictionary  of  Medicine,  Biology,  and  Allied  Sciences. 

Being  an  Exhaustive  Lexicon  of  Medicine  and  those  Sciences  Collateral  to  it : 
Biology  (Zoology  and  Botany),  Chemistry,  Dentistry,  Pharmacology,  Microscopy, 
etc.  By  George  M.  Gould,  m.d..  Formerly  Editor  of  The  Medical  News ; 
President  American  Academy  of  Medicine ;  Ophthalmologist  Philadelphia  Hos- 
pital, etc.  With  many  Useful  Tables  and  numerous  Fine  Illustrations.  Large, 
Square  Octavo.     1633  pages.     Third  Edition  now  Ready. 

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Tables  of  the  Bacilli,  Micrococci,  Leucomains,  Ptomains,  etc.,  of  the  Arteries, 
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GOWERS.  Manual  of  Diseases  of  the  Nervous  System.  A  Complete  Text-book. 
By  William  R.  Gowers,  m.d.,  f.r.s.,  Prof.  Clinical  Medicine,  University  College, 
London.  Physician  to  National  Hospital  for  the  Paralyzed  and  Epileptic.  Second 
Edition.  Revised,  Enlarged  and  in  many  parts  rewritten.  With  many  new 
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Syphilis  and  the  Nervous  System.    Being  a  revised  reprint  of  the  Lettso- 

mian  Lectures  for  1890,  delivered  before  the  Medical  Society  of  London. 

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HAIG.  Causation  of  Disease  by  Uric  Acid.  A  Contribution  to  the  Pathology  of 
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HALL.  Compend  of  General  Pathology  and  Morbid  Anatomy.  By  H.  Newbery 
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HANSELL  and  BELL.  Clinical  Ophthalmology,  Illustrated.  A  Manual  for 
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Ophthalmology  in  the  Jefferson  College  Hospital,  Philadelphia,  etc.,  and  James 
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HARE.  Mediastinal  Disease.  The  Pathology,  Clinical  History  and  Diagnosis  of 
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Hare,  m.d.  (Univ.  of  Pa.),  Professor  of  Materia  Medica  and  Therapeutics  in 
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MEDICAL  AND  SCIENTIFIC  PUBLIC  A  TIONS.  13 

HARLAN.  Eyesight,  and  How  to  Care  for  It.  By  George  C.  Harlan,  m.d., 
Prof,  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic.     Illustrated.         Cloth,  .40 

HARRIS'S  Principles  and  Practice  of  Dentistry,  Including  Anatomy,  Physi- 
ology, Pathology,  Therapeutics,  Dental  Surgery  and  Mechanism.  By  Chapin  A. 
Harris,  m.d.,  d.d.s.,  late  President  of  the  Baltimore  Dental  College,  author  of 
"  Dictionary  of  Medical  Terminology  and  Dental  Surgery."  Thirteenth  Edition. 
Revised  and  Edited  by  Ferdinand  J.  S.  Gorgas,  a.m.,  m.d.,  d.d.s.,  author  of 
"Dental  Medicine;"  Professor  of  the  Principles  of  Dental  Science,  Dental 
Surgery  and  Dental  Mechanism  in  the  University  of  Maryland.  1250  Illustra- 
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Dictionary  of  Dentistry.  Fifth  Edition,  Revised.  Including  Definitions  of 
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Practice  of  Dentistry.  Fifth  Edition.  Rewritten,  Revised  and  Enlarged. 
By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s..  Author  of  "Dental  Medicine;" 
Editor  of  Harris's  "Principles  and  Practice  of  Dentistry;"  Professor  of 
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University  of  Maryland.     Octavo.  Cloth,  $4.50  ;  Leather,  $5.50 

HARRIS  and  BEALE.  Treatment  of  Pulmonary  Consumption.  By  Vincent 
Dormer  Harris,  m.d.  (Lond.),  f.r.c.p.,  Physician  to  the  city  of  London  Hospi- 
tal for  Diseases  of  the  Chest;  Examining  Physician  to  the  Royal  National  Hos- 
pital for  Diseases  of  the  Chest,  Ventnor,  etc.,  and  E.  Clifford  Beale,  m.a., 
M.B.  (Cantab.),  f.r.c.p.,  Physician  to  the  city  of  London  Hospital  for  Diseases 
of  the  Chest,  and  to  the  Great  Northern  Central  Hospital,  etc.  A  Practical 
Manual.     i2mo.  Cloth,  ^2.50 

HARTRIDGE:    Refraction.     The  Refraction  of  the  Eye.     A  Manual  for  Students. 
By  GuSTAVUS  Hartridge,  F.R.C.S.,  Consulting  Ophthalmic  Surgeon  to  St.  Bar- 
tholomew's Hospital ;  Ass't  Surgeon  to  the  Royal  Westminster  Ophthalmic  Hos- 
pital, etc.     98  Illustrations  and  Test  Types.     Seventh  Edition.  Cloth,  $1.00 
On  The  Ophthalmoscope.     A  Manual  for  Physicians  and  Students.     Second 
Edition.    With  Colored  Plates  and  many  Woodcuts.     i2mo.        Cloth,  $1.25 

HARTSHORNE.  Our  Homes.  Their  Situation,  Construction,  Drainage,  etc.  By 
Henry  Hartshorne,  m.d.     Illustrated.  Cloth,  .40 

HATFIELD.  Diseases  of  Children.  By  Marcus  P.  Hatfield,  Professor  ot 
Diseases  of  Children,  Chicago  Medical  College.  With  a  Colored  Plate.  Second 
Edition.     Being  No.  14,  ?  Quiz-Conpend?  Series.     i2mo.  Cloth,  .80 

Interleaved  for  the  addition  of  notes,  ^1.25 

HEATH.    Minor  Surgery  and  Bandaging.    By  Christopher  Heath,  f.r.c.s., 

Holme   Professor  of  Clinical   Surgery   in   University  College,  London.     Tenth 

Edition.      Revised  and   Enlarged.     With   158    Illustrations,  62   Formulae,  Diet 

List,  etc.     i2mo.  Cloth,  I1.25 

Practical  Anatomy.      A  Manual  of  Dissections.      Eighth  London  Edition. 

300  Illustrations.  Cloth,  I4.25 

Injuries  and  Diseases  of  the  Jaws.    Fourth  Edition.    Edited  by  Henry 

Percy   Dean,   m.s.,  f.r.c.s..  Assistant  Surgeon    London  Hospital.     With 

187  Illustrations.    8vo.  Cloth,  $4.50 

Lectures  on  Certain  Diseases  of  the  Jaws,  delivered  at  the  Royal  College  of 

Surgeons  of  England,  1887.     64  Illustrations.     8vo.  Boards,  .50 

HENRT.  Anaemia.  A  Practical  Treatise.  By  Fred'k  P.  Henry,  m.d..  Physician 
to  Episcopal  Hospital,  Philadelphia.  Half  Cloth,  .50 


14  P.  BLAK/STON,  SON  &-  CO:S 

HOLDEN'S  Anatomy.  Sixth  Edition.  A  Manual  of  the  Dissections  of  the  Human 
Body.  By  John  Langton,  f.r.c.s.,  Surgeon  to,  and  Lecturer  on  Anatomy  at, 
St.  Bartholomew's  Hospital.  Carefully  Revised  by  A.  Hewson,  m.d..  Demonstra- 
tor of  Anatomy,  Jefferson  Medical  College ;  Chief  of  Surgical  Clinic,  Jefferson 
Hospital;  Mem.  Assoc.  Amer.  Anatomists,  etc.  311  Illustrations.  i2mo.  800 
pages.  Cloth,  $2.50;  Oil-cloth,  $2.50 ;  Leather,  $3.00 

Human  Osteolog'y.  Comprising  a  Description  of  the  Bones,  with  Colored 
Delineations  of  the  Attachments  of  the  Muscles.  The  General  and  Micro- 
scopical Structure  of  Bone  and  its  Development.  Carefully  Revised,  by 
the  Author  and  Prof.  Stewart,  of  the  Royal  College  of  Surgeons'  Museum. 
With  Lithographic  Plates  and  Numerous  Illustrations.  7th  Ed.  Cloth,  ^5.25 
Landmarks.     Medical  and  Surgical.     4th  Edition.     8vo.  Cloth,  $1.00 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common  Poisons  and  the 
Milk.  Memoranda,  Chemical  and  Microscopical,  for  Laboratory  Use.  By  J.  W. 
Holland,  m.d..  Professor  of  Medical  Chemistry  and  Toxicology  in  Jefferson 
Medical  College,  of  Philadelphia.  Fifth  Edition,  Enlarged.  Illustrated  and 
Interleaved.  i2mo.  Cloth, ;^i.oo 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and  Functions  of.  Being 
the  FuUerian  Lectures  on  Physiology  for  1891.  By  Victor  A.  Horsley,  m.b., 
F.R.S.,  etc..  Assistant  Surgeon,  University  College  Hospital,  Professor  of  Pathology, 
University  College,  London,  etc.     With  numerous  Illustrations.  Cloth,  $2.50 

HORWITZ'S  Compend  of  Surgery,  including  Minor  Surgery,  Amputations,  Frac- 
tures, Dislocations,  Surgical  Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with 
Differential  Diagnosis  and  Treatment.  By  Orville  Horwitz,  b.s.,  m.d..  Pro- 
fessor of  Genito-Urinary  Diseases,  late  Demonstrator  of  Surgery,  Jefferson  Medi- 
cal College.  Fifth  Edition.  Very  much  Enlarged  and  Rearranged.  Over  300 
pages.     167  Illustrations  and  98  Formulae.    i2mo.  A^o.g  ? Quiz- Compend?  Series. 

Cloth,  .80.     Interleaved  for  notes,  $1.25 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharynx.  A  Treatise  including 
Anatomy  and  Physiology  of  the  Organ,  together  with  the  treatment  of  the  affec- 
tions of  the  Nose  and  Pharynx  which  conduce  to  aural  disease.  By  T.  Mark 
HovELL,  F.R.C.S.  (Edin.),  M.R.c.s.  (Eng.),  Aural  Surgeon  to  the  London  Hospital, 
to  Hospital  for  Diseases  of  the  Throat,  and  to  British  Hospital  for  Incurables, 
etc.     122  Illustrations.     Octavo.  Cloth,  $5.00 

HUGHES.  Compend  of  the  Practice  of  Medicine.  Fifth  Edition.  Revised  and 
Enlarged.  By  Daniel  E.  Hughes,  m.d.,  Demonstrator  of  Clinical  Medicine  at 
Jefferson  Medical  College,  Philadelphia.  In  two  parts.  Being  Nos.  2  and  j, 
?  Quiz-  Co7npend  f  Series. 

Part  1. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases  of  the  Stomach, 
Intestines,  Peritoneum,  Biliary  Passages,  Liver,  Kidneys,  etc.,  and  General 
Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System,  Circulatory  System  and  Ner- 
vous System  ;  Diseases  of  the  Blood,  etc. 

Price  of  each  Part,  in  Cloth,  .80 ;  interleaved  for  the  addition  of  Notes,  ^1.25 
Physicians'  Edition. — In  one  volume,  including  the  above  two  parts,  a  sec- 
tion on  Skin  Diseases,  and  an  index.      Fifth  revised,  enlarged  Edition. 
^68  pages.  Full  Morocco,  Gilt  Edge,  $2.25 

"  Carefully  and  systematically  compiled." — The  London  Lancet. 
HUMPHREY.  A  Manual  for  Nurses.  Including  general  Anatomy  and  Physiology, 
management  of  the  sick-room,  etc.  By  Laurence  Humphrey,  m.a.,  m.b., 
M.R.c.s.,  Assistant  Physician  to,  and  Lecturer  at,  Addenbrook's  Hospital,  Cam- 
bridge, England.  Thirteenth  Edition.  i2mo.  Illustrated.  Cloth,  $1.00 
HYSLOP'S  MENTAL  PHYSIOLOGY.  Especially  in  its  Relation  to  Mental  Dis- 
orders. By  Theo.  B.  Hyslop,  m.d..  Lecturer  on  Mental  Diseases,  St.  Mary's 
Hospital  Medical  School,  Assistant  Physician,  Bethlem  Royal  Hospital,  London, 
With  Illustrations.     i2mo.  Cloth,  $4.25 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  15 

HUTCHINSON.  The  Nose  and  Throat.  A  Manual  of  the  Diseases  of  the  Nose 
and  Throat,  inchiding  the  Nose,  Naso-Pharynx,  Pharynx  and  Larynx.  By 
Procter  S.  Hutchinson,  m.r.c.s.,  Ass't  Surgeon  to  the  London  Hospital  for 
Diseases  of  the  Throat.  Illustrated  by  Lithograph  Plates  and  40  other  lUus., 
many  of  which  have  been  made  from  original  drawings.    i2mo.    2d  Ed.    In  Press, 

IMPEY.  A  Handbook  on  Leprosy.  By  S.  P.  Impey,  m.d.,  m.c,  Late  Chief  and 
Medical  Superintendent,  Robben  Island  Leper  and  Lunatic  Asylums,  Gape  Col- 
ony, South  Africa.     Illustrated  by  37  Plates  and  a  Map.     Octavo.      Cloth,  $3.50 

JACOBSON.     Operations  of  Surgery.     By  W.  H.  A.  Jacobson,  b.a.  oxon., 

F.R.C.S.,  Eng. ;  Ass't  Surgeon,  Guy's  Hospital ;    Surgeon  at  Royal  Hospital  for 

Children  and  Women,  etc.     With  over  200  lUust.      Cloth,  ^3.00  ;  Leather,  $4.00 

Diseases  of  the  Male  Organs  of  Generation.    88  Illustrations.    Cloth,  $6.00 

JONES.  Medical  Electricity.  A  Practical  Handbook  for  Students  and  Prac- 
titioners of  Medicine.  By  H.  Lewis  Jones,  m.a.,  m.d.,  m.r.c.p..  Medical  Officer 
in  Charge  Electrical  Department,  St.  Bartholomew's  Hospital.  Second  Edition 
of  Steavenson  and  Jones'  Medical  Electricity.  Revised  and  Enlarged.  112  Illus- 
trations.    i2mo.  Cloth,  $2.50 

KENWOOD.    Public  Health  Laboratory  Work.     By  H.  R.  Kenwood,  m.b.. 

D.P.H.,  F.C.S.,  Instructor  in  Hygienic  Laboratory,  University  College,  late  Assistant 

Examiner  in  Hygiene,  Science  and  Art  Department,  South  Kensington,  London, 

etc.     With  116  Illustrations  and  3  Plates.  Cloth,  ^2.00 

KIRKES'  Physiology.  (/?//^  Authorized  Edition.  i2mo.  Dark  Red  Cloth.) 
A  Handbook  of  Physiology.  Thirteenth  London  Edition,  Revised  and  Enlarged. 
By  W.  Morrant  Baker,  m.d.,  and  Vincent  Dormer  Harris,  m.d.  516  Illus- 
trations, some  of  which  are  printed  in  Colors.  i2mo.  Cloth,  ^3.25  ;  Leather,  ^4,00 

KLEEN.  Handbook  of  Massage.  By  Emil  Kleen,  m.d.,  ph.d.,  Stockholm  and 
Carlsbad.  Authorized  Translation  from  the  Swedish,  by  Edward  Mussey  Hart- 
well,  m.d.,  PH.D.,  Director  of  Physical  Training  in  the  Public  Schools  of  Boston. 
With  an  Introduction  by  Dr.  S.  Weir  Mitchell,  of  Philadelphia.  Illustrated 
with  a  series  of  Photographs  made  specially  by  Dr.  Kleen  for  the  American 
Edition.     Bvo.  Cloth,  $2.25 

LANDIS'  Compend  of  Obstetrics  ;  especially  adapted  to  the  Use  of  Students  and 
Physicians.  By  Henry  G.  Landis,  m.d.  Fifth  Edition.  Revised  by  Wm.  H. 
Wells,  m.d.,  Ass't  Demonstrator  of  Clinical  Obstetrics,  Jefferson  Medical  College ; 
Member  Obstetrical  Society  of  Philadelphia,  etc.  Enlarged.  With  Many  Illus- 
trations.    No.  ^  ?  Quiz- Compend  f  Series. 

Cloth,  .80;  interleaved  for  the  addition  of  Notes,  I1.25 

LANDOIS.  A  Text-Book  of  Human  Physiology ;  including  Histology  and  Micro- 
scopical Anatomy,  with  special  reference  to  the  requirements  of  Practical  Medi- 
cine. By  Dr.  L.  Landois,  Professor  of  Physiology  and  Director  of  the  Physio- 
logical Institute  in  the  University  of  Greifswald.  Fifth  American,  translated 
from  the  last  German  Edition,  with  additions,  by  Wm.  Stirling,  m.d.,  d.Sc, 
Brackenbury  Professor  of  Physiology  and  Histology  in  Owen's  College,  and  Pro- 
fessor in  Victoria  University,  Manchester  ;  Examiner  in  Physiology  in  University 
of  Oxford,  England.  With  845  Illustrations,  many  of  which  are  printed  in 
Colors.     8vo.  In  Press. 

LEE.  The  Microtomist's  Vade  Mecum.  Fourth  Edition.  A  Handbook  of 
Methods  of  Microscopical  Anatomy.  By  Arthur  Bolles  Lee,  Ass't  in  the  Rus- 
sian Laboratory  of  Zoology,  at  Villefranche-sur-Mer  (Nice).  881  Articles.  En- 
larged and  Revised.     Octavo.  In  Press. 


16  P.  BLAKISTON,  SON  <S-  CO:S 

LEFFMANN'S  Compend  of  Medical  Chemistry,  Inorganic  and  Organic.  In- 
cluding Urine  Analysis.  By  Henry  Leffmann,  m.d.,  Prof,  of  Chemistry  and 
Metallurgy  in  the  Penna.  College  of  Dental  Surgery  and  in  the  Wagner  Free 
Institute  of  Science,  Philadelphia.  No.  jo  ?  Quiz- Compend  f  Series.  Fourth 
Edition.    Rewritten.  Cloth,  .80.    Interleaved  for  the  addition  of  Notes,  $1.25 

The  Coal-Tar  Colors,  with  Special  Reference  to  their  Injurious  Qualities  and 
the  Restrictions  of  their  Use.     A  Translation  of  Theodore  Weyl's  Mono- 
graph.    i2mo.  Cloth,  $1.25 
Progressive  Exercises  in  Practical  Chemistry.    A  Laboratory  Handbook. 
Illustrated.     Third  Edition,  Revised  and  Enlarged.     i2mo.      Cloth.  $1.00 

Examination  of  Water  for  Sanitary  and  Technical  Purposes.    Third  Edition. 
Enlarged.     Illustrated.     i2mo.  Cloth,  $1.25 

Analysis  of  Milk  and  Milk  Products.    Arranged  to  suit  the  needs  of  Analyt- 
ical Chemists,  Dairymen,  and  Milk  Inspectors.     i2mo.  Cloth,  $1.25 
LEGG    on  the  Urine.      Practical    Guide   to   the   Examination    of   Urine.      By  J. 
WiCKHAM  Legg,  m.d.     Seventh  Edition,'  Enlarged.     Edited  and  Revised  by  H. 
Lewis  Jones,  m.a.,  m.d.,  m.r.c.p.     Illustrated.     i2mo.  Cloth,  ^i.oo 
LEWERS.    On  the  Diseases  of  Women.    A  Practical  Treatise.    By  Dr.  A.  H. 
N.  Lewers,  Assistant  Obstetric  Physician  to  the  London  Hospital ;  and  Phy- 
sician to  Out-patients,  Queen  Charlotte's  Lying-in  Hospital;  Examiner  in  Mid- 
wifery and  Diseases  of  Women  to  the  Society  of  Apothecaries  of  London.     With 
146  Engravings.     Third  Edition,  Revised.  Cloth,  $2.00 
LEWIS  (BEVAN).    Mental  Diseases.  A  text-book  having  special  reference  to  the 
Pathological  aspects  of  Insanity.     By  Bevan  Lewis,   l.r.c.p.,  m.r.c.s..  Medi- 
cal Director,  West  Riding  Asylum,  Wakefield,  England.     18  Lithographic  Plates 
and  other  Illustrations.     Second  Edition.     8vo.  In  Press. 
LINCOLN.    School  and  Industrial  Hygiene.    By  D.  F.  Lincoln,  m.d.    Cloth,  .40 
LIZARS  (JOHN).     On  Tobacco.     The  Use  and  Abuse  of  Tobacco.           Cloth,  .40 
LONGLEY'S  Pocket  Medical  Dictionary  for  Students  and  Physicians.    Giving 
the  Correct  Definition  and  Pronunciation  of  all  Words  and  Terms  in  General 
Use  in  Medicine   and  the  Collateral   Sciences,  with   an  Appendix,  containing 
Poisons  and  their  Antidotes,  Abbreviations  Used  in  Prescriptions,  and  a  Metric 
Scale  of  Doses.     By  Elias  Longley.             Cloth,  .75  ;  Tucks  and  Pocket,  $1.00 

MACALISTER'S  Human  Anatomy.  800  Illustrations.  A  New  Text-book  for 
Students  and  Practitioners.  Systematic  and  Topographical,  including  the 
Embryology,  Histology  and  Morphology  of  Man.  With  special  reference  to  the 
requirements  of  Practical  Surgery  and  Medicine.  By  Alex.  Macalister,  m.d., 
F.R.S.,  Professor  of  Anatomy  in  the  University  of  Cambridge,  England ;  Examiner 
in  Zoology  and  Comparative  Anatomy,  University  of  London ;  formerly  Professor 
of  Anatomy  and  Surgery,  University  of  Dublin.  With  816  Illustrations,  400  of 
which  are  original.     Octavo.  Cloth,  $5.00;  Leather,  $6.co 

MACDONALD'S  Microscopical  Examinations  of  Water  and  Air.  With  an  Ap- 
pendix on  the  Microscopical  Examination  of  Air.  By  J.  D.  Macdonald,  m.d. 
25  Lithographic  Plates,  Reference  Tables,  etc.     Second  Ed.     8vo.      Cloth,  $2.50 

MACKENZIE.  The  Pharmacopoeia  of  the  London  Hospital  for  Diseases  of 
the  Throat.  By  Sir  Morell  Mackenzie,  m.d.  Fifth  Edition.  Revised  and 
Improved  by  F.  G.  Harvey,  Surgeon  to  the  Hospital.  Cloth,  ^i.oo 

MACNAMARA.  On  the  Eye.  A  Manual.  By  C.  Macnamara,  m.d.  Fifth 
Edition,  Carefully  Revised;  with  Additions  and  Numerous  Colored  Plates,  Dia- 
grams of  Eye,  Wood-cuts,  and  Test  Types.     Demi  Svo.  Cloth,  I3.50 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  17 

MACREADY.  A  Treatise  on  Ruptures.  By  Jonathan  F.  C.  H.  Macready, 
F.K.C.S.,  Surgeon  to  the  Great  Northern  Central  Hospital ;  to  the  City  of  London 
Hospital  for  Diseases  of  the  Chest ;  to  the  City  of  London  Truss  Society,  etc. 
With  24  full-page  Lithographed  Plates  and  numerous  Wood-Engravings.  Octavo. 

Cloth,  $6.00 

MANN.  Forensic  Medicine  and  Toxicology.  A  Text-Book  by  J.  Dixon  Mann, 
M.D.,  F.R.C.P.,  Professor  of  Medical  Jurisprudence  and  Toxicology  in  Owens  Col- 
lege, Manchester ;  Examiner  in  Forensic  Medicine  in  University  of  London,  etc. 
Illustrated.     Octavo.  Cloth,  $6.50 

MANN'S  Manual  of  Psychological  Medicine  and  Allied  Nervous  Diseases.  Their 
Diagnosis,  Pathology,  Prognosis  and  Treatment,  including  their  Medico-Legal 
Aspects  ;  with  chapter  on  Expert  Testimony,  and  an  abstract  of  the  laws  relating 
to  the  Insane  in  all  the  States  of  the  Union.  By  Edward  C.  Mann,  m.d., 
member  of  the  New  York  County  Medical  Society.  With  Illustrations  of  Typical 
Faces  of  the  Insane,  Handwriting  of  the  Insane,  and  Micro-photographic  Sec- 
tions of  the  Brain  and  Spinal  Cord.     Octavo.  Cloth,  $3.00 

MARSHALL'S  Physiological  Diagrams,  Life  Size,  Colored.    Eleven  Life-size 
Diagrams  (each  7  feet  by  3  feet  7  inches).     Designed  for  Demonstration  before 
the   Class.    By  John  Marshall,  f.r.s.,  f.r.c.s.,  Professor  of  Anatomy  to  the 
Royal  Academy ;  Professor  of  Surgery,  University  College,  London,  etc. 

In  Sheets  Unmounted,  ^40.00 
Backed  with  Muslin  and  Mounted  on  Rollers,  ^60.00 
Ditto,  Spring  Rollers,  in  Handsome  Walnut  Wall  Map  Case  (Send  for 

Special  Circular),         ..........       ^100.00 

Single  Plates,  Sheets,  $5.00;  Mounted,  $7.50;  Explanatory  Key,  50  cents. 
No.  I — The  Skeleton  and  Ligaments.  No.  2 — The  Muscles  and  Joints,  with 
Animal  Mechanics.  No.  3 — The  Viscera  in  Position.  The  Structure  of  the  Lungs. 
No.  4 — The  Heart  and  Principal  Blood-vessels.  No.  5 — The  Lymphatics  or  Absorb- 
ents. No.  6 — The  Digestive  Organs.  No.  7 — The  Brain  and  Nerves.  Nos.  8  and  9 — 
The  Organs  of  the  Senses.  Nos,  10  and  11 — The  Microscopic  Structure  of  the 
Textures  and  Organs.     {Send for  Special  Circular.) 

MASON'S  Compend  of  Electricity,  and  its  Medical  and  Surgical  Uses.  By 
Charles  F.  Mason,  m.d..  Assistant  Surgeon  U.  S.  Army.  With  an  Intro- 
duction by  Charles  H.  May,  m.d..  Instructor  in  the  New  York  Polyclinic. 
Numerous  Illustrations.     i2mo.  Cloth,  .75 

MAXWELL.  Terminologia  Medica  Polyglotta.  By  Dr.  Theodore  Maxwell, 
assisted  by  others  in  various  countries.     8vo.  Cloth,  $3.00 

The  object  of  this  work  is  to  assist  the  medical  men  of  any  nationality  in  reading  medical  literature  written 
in  a  language  not  their  own.  Each  term  is  usually  given  in  seven  languages,  viz. :  English,  French,  German, 
Italian,  Spanish,  Russian  and  Latin. 

MAYS'  Therapeutic  Forces  ;  or.  The  Action  of  Medicine  in  the  Light  of  the  Doc- 
trine of  Conservation  of  Force.     By  Thomas  J.  Mays,  m.d.  Cloth,  $1.2^, 
Theine  in  the  Treatment  of  Neuralgia.     i6mo.                        ^  bound,  .50 

McBRIDE.  Diseases  of  the  Throat,  Nose  and  Ear.  A  Clinical  Manual  for  Stu- 
dents and  Practitioners.  By  P.  McBride,  m.d.,  f.r.c.p.  (Edin.),  Surgeon  to  the 
Ear  and  Throat  Department  of  the  Royal  Infirmary;  Lecturer  on  Diseases  of 
Throat  and  Ear,  Edinburgh  School  of  Medicine,  etc.  With  Colored  Illustrations 
from  Original  Drawings.    2d  Edition.    Octavo.       Handsome  Cloth,  Gilt  top,  $6.00 

McNEILL.  The  Prevention  of  Epidemics  and  the  Construction  and  Man- 
agement of  Isolation  Hospitals.  By  Dr.  Roger  McNeill,  Medical  Officer  of 
Health  for  the  County  of  Argyll.  With  numerous  Plans  and  other  Illustrations. 
Octavo.  Cloth,  $3.50 


18  P.   FLAKISTON,  SON  &^  CO.'S 

MEIGS,  Milk  Analysis  and  Infant  Feeding^.  A  Treatise  on  the  Examination  of 
Human  and  Cows'  Milk,  Cream,  Condensed  Milk,  etc.,  and  Directions  as  to  the 
Diet  of  Young  Infants.     By  Arthur  V.  Meigs,  m.d.     i2mo.  Cloth,  .50 

MEMMINGER.  Diagnosis  by  the  Urine.  The  Practical  Examination  of  Urine, 
with  Special  Reference  to  Diagnosis.  By  Allard  Memminger,  m.d.,  Professor 
of  Chemistry  and  of  Hygiene  in  the  Medical  College  of  the  State  of  S.  C. ;  Visiting 
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SCOVILLE.  The  Art  of  Compounding.  A  Text-book  for  Students  and  a  Refer- 
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plied Pharmacy  and  Director  of  the  Pharmaceutical  Laboratory  in  the  Massa- 
chusetts College  of  Pharmacy.  Cloth,  $2.50 

SAXSOM.  Diseases  of  The  Heart.  The  Diagnosis  and  Pathology  of  Diseases  of 
the  Heart  and  Thoracic  Aorta.  By  A.  Ernest  Sansom,  m.d.,  f.r.c.p.,  Physician 
to  the  London  Hospital,  Examiner  in  Medicine  Royal  College  of  Physicians,  etc. 
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SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An  Introduction 
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Comprising  the  Botanical  and  Physical  Characteristics,  Source,  Constituents,  and 
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Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of  Kansas,  Mem- 
ber of  the  Committee  of  Revision  of  the  U.  S.  Pharmacopceia,  1890.  A  Glossary 
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SCHULTZE.  Obstetrical  Diagrams.  Being  a  Series  of  20  Colored  Lithograph 
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explanatory  (German)  text,  illustrated  by  wood-cuts.  By  Dr.  B.  S.  Schultze, 
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Price,  in  Sheets,  $26.00 ;  Mounted  on  Rollers,  Muslin  Backs,  $36.00 

SEWELL.  Dental  Surgery,  including  Special  Anatomy  and  Surgery.  By  Henry 
Sewell,  M.R.C.S.,  L.D.S.,  President  Odontological  Society  of  Great  Britain.  3d 
Edition,  greatly  enlarged,  with  about  200  Illustrations.  Cloth,  $2.00 

SHAWE.  Notes  for  Visiting  Nurses,  and  all  those  interested  in  the  working  and 
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SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  of  all  the  Princi- 
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firmary ;  Lecturer  on  Surgery,  Bristol  Medical  School ;  Late  Examiner  in  Surgery, 
University  of  Aberdeen,  etc.   Over  80  Illustrations.    Fifth  Edition.        Preparing. 

SMITH.  Electro-Chemical  Analysis.  By  Edgar  F.  Smith,  Professor  of  Chem- 
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SMITH  AND  KELLER.  Experiments.  Arranged  for  Students  in  General  Chem- 
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24  P.  BLAKISTON,  SON  &-  CO.'S 

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KINSON,  A.M.,  Wittenberg  College,  Springfield,  Ohio.     i2mo.  Cloth.  .50 

STARLING.  Elements  of  Human  Physiology.  By  Ernest  H.  Starling,  m.d. 
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in  Yale  University,  Member  of  the  American  Medico-Psychological  Ass'n,  Hon- 
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cal Jurisprudence  at  Guy's    Hospital,  London,  etc.,  and  Shirley  F.  Murphy, 
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STIRLING,  Outlines  of  Practical  Physiology.  Including  Chemical  and  Experi- 
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ling, M.D.,  Sc.d.,  Professor  of  Physiology  and  Histology,  Owens  College,  Victoria 
University,  Manchester.  Examiner  in  Physiology,  Universities  of  Edinburgh 
and  London,     Third  Edition,     289  Illustrations,  Cloth,  ^2.00 

Outlines  of  Practical  Histology.     368  Illustrations.     Second  Edition.     Re- 
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Belfast  Union  Infirmary  and  Fever  Hospital.     Octavo.  Cloth,  .75 

SWANZY.  Diseases  of  the  Eye  and  their  Treatment.  A  Handbook  for  Physi- 
cians and  Students.  By  Henry  R.  Swanzy,  a.m.,  m.b.,  f.r.c.s.i..  Surgeon  to 
the  National  Eye  and  Ear  Infirmary  ;  Ophthalmic  Surgeon  to  the  Adelaide  Hos- 
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Schaper,  Demonstrator  of  Histology  and  Embryology,  Harvard  Medical  School, 
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26  P.  BLAKISTON,  SON  &-  CO.'S 

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Dental  Surgery.    A  System  of  Dental  Surgery.    By  John  Tomes,  f.r.s. 
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WETHERED.  -Medical  Microscopy.  A  Guide  to  the  Use  of  the  Microscope  in 
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Practical  Medicine,  Middlesex  Hospital  Medical  School,  Assistant  Physician, 
late  Pathologist,  City  of  London  Hospital  for  Diseases  of  Chest,  etc.  With  100 
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WEYL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  By  Theodore  Weyl. 
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Moullin's  Surgery, 

Third  Edition,  Enlarged.     Just  Ready. 

A  Complete  Practical  Treatise  on  Surgery,  with  Special  Reference  to  Treatment. 

By  C.  W.  MANSELL  MOULLIN,  M.A.,  M.D.  Oxon.,  F.R.C.S., 

Surgeon  and  Lecturer  on  Physiology  to  the  London  Hospital,  etc. 


Third  American  Edition, 

Edited  by  JOHN  B.  HAMILTON,  M.D.,  LL.D., 

Professor  of  the  Principles  of  Surgery  and  Clinical   Surgery,  Rush  Medical  College,  Chicago ;    Professor  of 

Surgery,  Chicago  Polyclinic ;   Formerly  Supervising  Surgeon-General,  U.  S.  Marine  Hospital 

Service;   Surgeon  to  Presbyterian  Hospital,  St.  Joseph's  Hospital,  and  Central 

Free  Dispensary,  Chicago,  etc. 

Over  Six  Hundred  Illustrations, 

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Royal  8vo.    1250  Pages.   Handsome  Cloth,  $6.00 ;  Leather,  Raised  Bands,  $7.00. 

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the  character  of  the  whole  book,  in  that  it  has  been  worked  up  from  modern  ideas  and  methods 
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particular  attention  on  account  of  their  practical  bearing  on  useful  points  in  Surgery.  By  the 
addition  of  colors  to  many  of  these  the  text  is  thoroughly  elucidated,  impressing  at  once  upon 
the  mind  of  the  Surgeon  or  Student  the  real  relations  of  important  parts  of  the  Anatomy,  and 
certain  particular  diagnostic  features.  This  is  especially  patent  in  the  article  on  tumors,  where 
the  illustrations  of  sections  of  the  various  growths  have  been  colored  so  as  to  bring  out  with 
great  clearness  their  differential  diagnosis. 

From  the  New  York  Medical  Record.  ♦ 

"  Special  attention  is  given  throughout  to  treatment,  and  the  discussion  of  controverted 
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aim  and  object  of  surgery  at  the  present  day  is  to  assist  the  tissues  in  every  possible  way  in  their 
struggle  against  disease. 

"  From  such  a  standpoint  it  goes  without  saying  that  the  writer's  attitude  is  a  conservative 
one.  He  is,  however,  free  from  hesitancy,  and  shows  a  keen  appreciation  of  the  rapid  strides 
of  surgical  art  in  the  last  decade.  Wo  less  than  two  hundred  of  the  illustrations  were  drawn 
expressly  for  this  work.  It  has  all  the  conciseness  of  Druitt's  well-known  work,  and  the 
advantage  of  a  somewhat  more  extensive  description  of  certain  conditions  occurring  in  practical 
work." 
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?  Quiz-Compends  ?.  They  are  well  arranged,  full,  and  concise,  and  are  really  the  best  line  of  text- 
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BLAKISTON'S  ?QU1Z=C0MPENDS? 

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Price  of  each,  Cloth,  .80.  Interleaved,  for  taking  Notes,  $1.25. 

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and  are  kept  constantly  revised,  so  that  they  may  thoroughly  represent  the  present  state  of  the  subjects  upon 
■which  they  treat. 

4®"  The  authors  have  had  large  experience  as  Quiz-Masters  and  attaches  of  colleges,  and  are  well 
acquainted  with  the  wants  of  students. 

4®"  They  are  arranged  in  the  most  approved  form,  thorough  and  concise,  containing  over  600  fine  illustra- 
tions, inserted  wherever  they  could  be  used  to  advantage. 

4®~  Can  be  used  by  students  of  any  college. 

4®^  They  contain  information  nowhere  else  collected  in  a  such  a  condensed,  practical  shape. 

ILLUSTRATED  CIRCULAR  FREE. 

No.  I.  HUMAN  ANATOMY.  Fifth  Revised  and  Enlarged  Edition.  Including  Visceral  Anatomy.  Can 
be  used  with  either  Morris's  or  Gray's  Anatomy.  117  Illustrations  and  16  Lithographic  Plates  of  Nerves  and 
Arteries,  with  Explanatory  Tables,  etc.  By  Samuel  O.  L.  Potter,  m.d..  Professor  of  the  Practice  of 
Medicine,  Cooper  Medical  College,  San  Francisco;  late  A.  A.  Surgeon,  U.  S.  Army. 

No.  2.  PRACTICE  OF  MEDICINE.  Part  I.  Fifth  Edition,  Revised,  Enlarged,  and  Improved.  By 
Dan'l  E.  Hughes,  m.d. ,  Physician-in-Chief,  Philadelphia  Hospital,  late  Demonstrator  of  Clinical  Medi- 
cine, Jefferson  Medical  College,  Philadelphia. 

No.  3.  PRACTICE  OF  MEDICINE.  Part  II.  Fifth  Edition,  Revised,  Enlarged,  and  Improved.  Same 
author  as  No.  2. 

No.  4.  PHYSIOLOGY.  Seventh  Edition,  with  new  Illustrations  and  a  table  of  Physiological  Constants. 
Enlarged  and  Revised.  By  A.  P.  Brubaker,  m.d..  Professor  of  Physiology  and  General  Pathology  in  the 
Pennsylvania  College  of  Dental  Surgery ;  Demonstrator  of  Physiology,  Jefferson  Medical  College,  Phila- 
delphia. 

No.  5.  OBSTETRICS.  Fifth  Edition.  By  Henry  G.  Landis,  m.d.  Revised  and  Edited  by  Wm.  H. 
Wells,  m.d.,  Assistant  Demonstrator  of  Obstetrics,  Jefferson  Medical  College,  Philadelphia.  Enlarged. 
47  Illustrations. 

No.  6.  MATERIA  MEDICA,  THERAPEUTICS,  AND  PRESCRIPTION  WRITING.  Sixth 
Revised  Edition  (U.  S.  P.  1890).  By  Samuel  O.  L  Potter,  m.d.  Professor  of  Practice,  Cooper  Medical 
College,  San  Francisco  :  late  A    A.  Surgeon,  U.  S.  Afmy. 

No.  7.  GYN.ffiCOLOGY.  A  New  Book.  By  Wm  H.  Wells,  m.d.,  Assistant  Demonstrator  of  Obstetrics, 
Jefferson  College,  Philadelphia.     Illu-^trated. 

No.  8.  DISEASES  OF  THE  EYE  AND  REFRACTION.  Second  Edition.  Including  Treatment  and 
Surgery.     By  L   Webster  Fox,  m  d.,  and  George  M.  Gould,  m.d.    With  39  Formulae  and  71  Illustrations. 

No.  9.  SURGERY,  Minor  Surgery,  and  Bandaging.  Fifth  Edition,  Enlarged  and  Improved.  By 
Orville  HoRWiTZ,  B.S.,  M.D.,  Clinical  Professor  ot  Geni to-Urinary  Surgery  and  Venereal  Diseases  in  Jef- 
ferson Medical  College  ;  Surgeon  to  Philadelphia  Hospital,  etc.     With  98  Formulae  and  71  Illustrations. 

No.  10.  MEDICAL,  CHEMISTRY.  Fourth  Edition.  Including  Urinalysis,  Animal  Chemistry.  Chemistry 
of  Milk,  Blood,  Tissues,  the  Secretions,  etc  By  Henry  Leffmann,  m.d..  Professor  of  Chemistry  in 
Pennsylvania  College  of  Dental  Surgery  and  in  the  Woman's  Medical  College,  Philadelphia. 

No.  II.  PHARMACY.  Fifth  Edition.  Based  upon  Prof.  Remington's  Text-Book  of  Pharmacy.  By  F. 
E.  Stewart,  m.d.,ph.g.,  late  Quiz-Master  in  Pharmacy  and  Chemistry,  Philadelphia  College  of  Pharmacy; 
Lecturer  at  Jefferson  Medical  College.     Carefully  revised  in  accordance  with  the  new  U.  S.  P. 

No.  12.  VETERINARY  ANATOMY  AND  PHYSIOLOGY.  Illustrated.  By  Wm.  R.  Ballou,  m  d.. 
Professor  of  Equine  Anatomy  at  New  York  College  of  Veterinary  Surgeons ;  Physician  to  Bellevue  Dis- 
pensary, etc.     With  29  graphic  Illustrations. 

No.  13.  DENTAL  PATHOLOGY  AND  DENTAL  MEDICINE.  Second  Edition,  Illustrated.  Con- 
taining all  the  most  noteworthy  points  of  interest  to  the  Dental  Student  and  a  Section  on  Emergencies.  By 
Geo.  W.  Warrkn,  d.d  s..  Chief  of  Clinical  Staff,  Pennsylvania  College  of  Dental  Surgery,  Philadelphia. 

No.  14.  DISEASES  OF  CHILDREN.  Colored  Plate.  By  Marcus  P.  Hatfield,  Professor  of  Dis- 
eases of  Children,  Chicago  Medical  College.     Second  Edition,  Enlarged. 

No.  15.  GENERAL  PATHOLOGY  AND  MORBID  ANATOMY.  91  Illustrations.  By  H.  New- 
berry Hall,  ph.g.,  m.d.,  Professor  of  Pathology  and  Medical  Chemistry,  Chicago  Post-Graduate  Medical 
School  ;  Member  Surgical  Staff,  Illinois  Charitable  Eye  and  Ear  Infirmary  ;  Chief  of  Ear  Clinic,  Chicago 
Medical  College.^ 

No.  16.     DISEASES  OF  NOSE  AND  EAR.     Illustrated.     Same  Author  as  No.  15. 

Price,  each,  .80.       Interleaved,  for  taking-  Notes,  $1.25. 

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The  PHYSICIAN'S  Visiting  List. 

(LINDSAY  &  BLAKISTON'S.) 

Special  ImproYed  Edition  for  1896. 


In  order  to  improve  and  simplify  this  Visiting  List  we  have  done  away  with  the  two 
styles  hitherto  known  as  the  "  25  and  50  Patients  plain,"  We  have  allowed  more  space 
for  writing  the  names,  and  added  to  the  special  memoranda  page  a  column  for  the 
"Amount"  of  the  weekly  visits  and  a  column  for  the  ''Ledger  Page."  To  do  this  with- 
out increasing  the  bulk  or  the  price,  we  have  condensed  the  reading  matter  in  the  front 
of  the  book  and  rearranged  and  simplified  the  memoranda  pages,  etc.,  at  the  back. 

The  Lists  for  75  Patients  and  100  Patients  will  also  have  special  memoranda  page  as 
above,  and  hereafter  will  come  in  two  volumes  only,  dated  January  to  June,  and  July  to 
December.  While  this  makes  a  book  better  suited  to  the  pocket,  the  chief  advantage  is 
that  it  does  away  with  the  risk  of  losing  the  accounts  of  a  whole  year  should  the  book 
be  mislaid. 

Before  making  these  changes  we  have  personally  consulted  a  number  of  physicians 
who  have  used  the  book  for  many  years,  and  have  taken  into  consideration  many  sugges- 
tions made  in  letters  from  all  parts  of  the  country. 


CONTENTS. 


PRELIMINARY  MATTER. — Calendar,  1896-1897 — Table  of  Signs,  to  be  used  in  keeping  records— 
The  Metric  or  French  Decimal  System  of  Weights  and  Measures — Table  for  Converting  Apothecaries' 
Weights  and  Measures  into  Grams — Dose  Table,  giving  the  doses  of  official  and  unofficial  drugs  in  both 
the  English  and  Metric  Systems — Asphyxia  and  Apnea — Complete  Table  for  Calculating  the  Period  of 
Utero-Gestalion — Comparison  of  Thermometers. 

VISITING  LIST. — Ruled  and  dated  pages  for  25,50, 75,  and  100  patients  per  day  or  week,  with  blank  page 
opposite  each  on  which  is  an  amount  column,  column  for  ledger  page,  and  space  for  special  memoranda. 

SPECIAL  RECORDS  for  Obstetric  Engagements,  Deaths,  Births,  etc.,  vpith  special  pages  for  Addresses 
of  Patients,  Nurses,  etc.,  Accounts  Due,  Cash  Account,  and  General  Memoranda. 


SIZES  AND    PRICES. 

REGULAR  EDITION,  as  Described  Above. 

BOUND    IN   STRONG   LEATHER  COVERS,  WITH    POCKET  AND    PENCIL. 

For  25  Patients  weekly,  with  Special  Memoranda  Page, $1  00 

50         "  "  "  "  " I   25 

,,  ,,  ,,  ,     f  January  to  Tune    "1  '  _, 

qo  "  "  "  "  "  2  vols.  ^•Ti.-T-il         y......200 

-'  (July  to  December  J 

"  "  "  "  '*        ■>      \     j  ]^^^^'^V  to  June    1  2  00 

'^  '(July  to   December/     ••:••■ 

100         "  «  "  "  "        2  vols  iJ^""^^y  ^°   J""^     \  7.2^ 

'  \  July  to  December  J  '    '    * 

PERPETUAL  EDITION,  without  Dates. 

No.  I.   Containing  space  for  over   1300  names,  with  blank  page  opposite  each  Visiting  List  page. 

Bound  in  Red  Leather  cover,  with  Pocket  and  Pencil, ^i   25 

No.  2.  Same  as  No.  I.     Containing  space  for  2600  names,  with  blank  page  opposite 15° 

MONTHLY  EDITION,  without  Dates. 

No.  I.   Bound,  Seal  leather,  without  Flap  or  Pencil,  gilt  edges, 75 

No.  2.  Bound,  Seal  leather,  with  Tucks,  Pencil,  etc.,  gilt  edges, i  00 

jji^"  All   these  prices  are  net.     No  discount  can  be  allowed  retail  purchasers. 
Circular  and  sample  pages  upon  application. 

P.   BLAKISTON,  SON  &  CO.,  Publishers,  Philadelphia. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  542  D34  1896  C.I 

A  treatise  on  apP6''|,S'|!uMn.|iiimiiii|iiiii|iil^ 


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